Intended use

Adults presenting to the ED with confirmed or suspected opioid use disorder who are not already on opioid agonist treatment.
Situations where you are deciding whether to initiate buprenorphine in the ED, delay until clearer withdrawal, or provide home/return induction instructions.
Pregnant patients with opioid use disorder where the immediate question is ED initiation versus urgent referral to pregnancy-specific services.

The calculator does not capture time since last opioid use, level of sedation, co-intoxication, acute medical instability, or suicide risk. These must be assessed separately.

Evidence context

Study	Setting and population	Intervention	Key findings
D'Onofrio et al., JAMA 2015	329 opioid-dependent adults at a US urban ED.	Randomised to referral only, brief intervention, or ED-initiated buprenorphine plus facilitated primary care follow up.	ED-initiated buprenorphine produced much higher engagement in addiction treatment at 30 days (about 78% vs 37–45% with referral/brief intervention) and a larger reduction in days of illicit opioid use, with less use of inpatient addiction services.
Melnick et al., BMJ 2022 (EMBED trial)	21 EDs in five US health systems caring for more than 5000 adults with opioid use disorder.	User-centred electronic health record decision support (EMBED) to guide diagnosis, withdrawal assessment, motivation, prescribing and referral versus usual care.	The CDS did not increase overall patient-level buprenorphine treatment rates, but a greater proportion of clinicians initiated buprenorphine at least once (44.4% vs 34.0%), suggesting modest behaviour change and the need for broader implementation strategies.
Simpson et al., Implement Sci Commun 2023	Qualitative interviews with 28 clinicians from EMBED intervention sites.	Explored barriers and facilitators to ED-initiated buprenorphine and to using the EMBED tool.	Successful use depended on organisational culture, clinician training and support, the ability to tailor workflows locally, and reliable pathways to ongoing treatment.

These studies support ED-initiated buprenorphine as an effective way to link people with opioid use disorder to ongoing treatment, while showing that decision support alone is insufficient without local protocols, champions and follow-up services.

In Australia, take-home naloxone is available free through the national Take Home Naloxone program. Overdose education and naloxone supply should accompany ED care for opioid use disorder, regardless of whether buprenorphine is started.

Emergency Department-Initiated Buprenorphine for Opioid Use Disorder (EMBED)