Methadone Initiation for Opioid Use Disorder in the Emergency Department

EP 03 🎙 Special Series: ASAM's 56th Annual Conference

This episode is part of a special four-part series spotlighting key sessions from ASAM’s 56th Annual Conference.

 

In this episode of ASAM Practice Pearls, In this episode of ASAM Practice Pearls, Dr. Elizabeth Salisbury-Afshar is joined by Drs. Rachel Haroz, Bill Soares, and Ryan McCormack to discuss their session, Methadone Initiation for Opioid Use Disorder in the Emergency Department. The episode covers implementation strategies, regulatory considerations, and practical steps for introducing methadone as a treatment option in emergency care.

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Elizabeth Salisbury-Afshar, MD, MPH, FAAFP, FACPM, DFASAM

Dr. Elizabeth Salisbury-Afshar is a family medicine, preventive medicine/public health, and addiction medicine physician. She is an Associate Professor at the University of Wisconsin School of Medicine and Public Health in Madison, Wisconsin. She is a core faculty member for the Addiction Medicine Fellowship at the University of Wisconsin, and her clinical roles include addiction medicine consult service and serving as medical director of a low-barrier walk-in clinic serving people who use substances. She is also the Program Director of the Preventive Medicine Residency at UW-Madison and Medical Director of Harm Reduction Services at the Wisconsin Division of Public Health. Dr. Salisbury-Afshar's work focuses on expanding access to evidence-based addiction treatment and harm reduction services. She has over 14 years of experience practicing in medically underserved settings. Dr. Salisbury-Afshar lectures nationally on addiction medicine topics, including the treatment of opioid use disorder, harm reduction, the intersection of addiction and the criminal legal system, and public health approaches to reduce overdose mortality. Dr. Salisbury-Afshar is actively involved in ASAM, where she currently serves as the Vice Chair of the Medical Education Council, Course Director of the ASAM-All Rise treatment courts courses, a member of the ASAM Conference Planning Committee, and the Chair of Harm Reduction Special Interest Group.

Expert

Rachel Haroz, MD, FAACT

Dr. Rachel Haroz is an associate professor in the Department of Emergency Medicine at Cooper Medical School of Rowan University, the division head of toxicology and addiction medicine, and the center head of the Cooper Center for Healing. She is board-certified in Emergency Medicine, Medical Toxicology, and Addiction Medicine, obtaining her BA in Biology from Brandeis University, her MD from Tufts University, and completing a residency in Emergency Medicine and a fellowship in Medical Toxicology. She has spent the last 20 years working in inner city emergency departments, mostly in the Camden area. She helped build and now staffs the Cooper Center for Healing in Camden, New Jersey, an addiction medicine specialty Center dedicated to treating patients with substance use disorders. In 2016, she helped create and implement BupeFirst ED, an initiative to prescribe buprenorphine from the Emergency Department and bridge patients to treatment with various community partners, and in 2019, she helped launch BupeFirst EMS, an innovative program aimed at initiating buprenorphine via paramedics in the field. She is also heavily involved in education as well as various NJ state initiatives to better serve patients struggling with substance use disorders.

Expert

Bill E. Soares III, MD, MS

Dr. William (Bill) Soares is the Director of Harm Reduction Services in the Department of Emergency Medicine at Baystate Medical Center in Springfield, MA, and an Assistant Professor of Emergency Medicine at the University of Massachusetts Chan Medical School-Baystate. He is a practicing emergency and addiction medicine physician researcher who has spent the past 10 years focused on expanding medication treatments and harm reduction services for emergency department patients with opioid use disorder. In his role as Director of Harm Reduction Services, Dr. Soares oversees take-home Narcan, harm reduction safer supply distribution, buprenorphine, and methadone induction programs throughout the four emergency departments in the Baystate Health System. Dr. Soares’s research focuses on clinical decision-making in the emergency department. He has completed a NIDA K08 (1K08DA045933-01) project evaluating provider decisions to prescribe discharge opioid medications to patients presenting with an acutely painful condition. He currently has federal grants from NIDA, AHRQ, and SAMHSA focused on expanding medication treatment and harm reduction for people with substance use disorders. Recently, he led efforts to create a comprehensive inpatient addiction consultation service for the three Baystate community hospitals through a state-level opioid settlement fund grant administered through the Massachusetts Bureau of Substance Use and Addiction Services (BSAS).

Expert

Ryan McCormack, MD, MS

Dr. Ryan McCormack is an Associate Professor of Emergency Medicine at the NYU Grossman School of Medicine and practices clinically in the Bellevue Hospital Emergency Department (ED). He is an NIH-funded clinical investigator who has led several multicenter trials with a history of funding from the National Institute on Drug Abuse (NIDA) and its Clinical Trials Network (CTN) and the National Institute on Alcohol Abuse and Alcoholism (NIAAA). His research employs mixed quantitative and qualitative methods and implementation science approaches to translate efficacious behavioral treatments (e.g., motivational interviewing, case management) and pharmacotherapy (buprenorphine, methadone, naltrexone) for substance use disorders into ED settings with a particular focus on highly marginalized patient populations.

📖 Show Segments

• 00:05 – Introduction
• 01:16 – The Evolution of Addiction Treatment in Emergency Departments
• 04:19 – Implementing Methadone Protocols: Steps and Best Practices
• 09:40 – Building Relationships and Finding Partners
• 14:32 – Navigating Federal and State Regulations
• 20:23 – The Importance of Multiple Treatment Options
• 23:39 – Policy Changes and the Future of Methadone Access
• 27:18 – Conclusion and Additional Learning Opportunities

📋 Key Takeaways

• Promote Multidisciplinary Support: Engage various stakeholders within the hospital, including clinical champions, nurses, residents, and administrative staff, to support methadone initiation.
• Partner with OTPs: Establish strong relationships with local Opioid Treatment Programs (OTPs) to ensure continuity of care for patients once they leave the emergency department.
• Implement Flexible Protocols: Develop clear, adaptable protocols for methadone initiation that can be tailored to your institution’s specific needs and resources.
• Offer Education and Training: Provide education and training to emergency department staff about methadone, including its benefits, dosing, and risk management.
• Familiarize Yourself with Policy and Regulations: Understand and navigate federal, state, and local regulations related to methadone. For guidance, use resources such as the State Opioid Treatment Authorities (SOTA). 
• Support Future Policy Shifts: Advocate for policy initiatives and legislative changes that could make methadone prescribing more flexible and accessible, potentially decentralizing it from tightly regulated OTPs. 
• Identify a Clinical Champion: Addiction pathways are organized, multidisciplinary care plans to support clinical guidelines and protocols. Identifying a clinical champion to help implement these addiction pathways is important for improving patient care.
• Consider Methadone for OUD Treatment in the ED: Methadone is a valuable, life-saving option for treating opioid use disorder. Don’t be afraid to use it. 

🔗 Resources

• ASAM’s 56th Annual Conference Session: Methadone Initiation for Opioid Use Disorder in the Emergency Department Register HERE
• Bridge Treatment: A program of the Public Health Institute that bridges emergency care and community health to create an integrated system that improves health and equity. 
• Clinical Toolkit - This toolkit provides referral algorithms, dosing strategies, risk stratification, literature/references, a guide to stakeholder recruitment and relationships, and tips of the trade.  
• Overview of Opioid Treatment Program Regulations by State – The Pew Charitable Trusts examines OTP regulations regarding access to care and patient experience across all 50 states and the District of Columbia as of June 2021. 
• State Opioid Treatment Authorities (SOTA) – SAMHSA provided list of SOTAs by state. 
• Clinical Guidelines for Withdrawal Management and Treatment of Drug Dependence in Closed Settings: Geneva: World Health Organization; 2009.  
• Emergency Department Utilization of the Methadone "72-Hour Rule" to Bridge or Initiate and Link to Outpatient Treatment: Huo S, Heil J, Salzman MS, et al. Am J Emerg Med. 2025;89:209-215. doi:10.1016/j.ajem.2024.12.059 
• Emergency Department-Initiated Buprenorphine/Naloxone Treatment for Opioid Dependence: A Randomized Clinical Trial: D'Onofrio G, O'Connor PG, Pantalon MV, et al. JAMA. 2015;313(16):1636-1644. doi:10.1001/jama.2015.3474 

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