Opioid use disorder (OUD) remains a persistent and evolving public health crisis in the United States. According to the Centers for Disease Control and Prevention, the nation is currently experiencing the third wave of the opioid epidemic.1
This is characterized by a transition from naturally derived and prescription opioids to synthetic opioids, particularly illicitly manufactured fentanyl and its cousins. More recently, some experts have described the emergence of a fourth wave, which is marked by the continued prevalence of synthetic opioids with additive agents, including sedatives such as xylazine.
Opioid-related mortalities increased substantially with a marked escalation beginning in 2013 and further exacerbation during the COVID-19 pandemic.¹ Recent data found a modest decline in opioid-related deaths, which is likely attributable to targeted public health interventions emphasizing harm reduction and improved access to medication for opioid use disorder treatment.2
Emergency medical services (EMS) have assumed an increasingly critical role in addressing this crisis. In 2024, the State of Vermont launched an innovative pilot program, Prehospital Vermont Buprenorphine Treatment (PREVENT), designed to expand prehospital interventions for the management of acute opioid withdrawal.3,4
This case study examines the implementation, successes, and challenges of PREVENT within a small municipal EMS agency serving a rural–suburban population of approximately 8,126 residents with an annual call volume of 1,800+ calls.5
Background and Literature Review
While EMS has long provided informal counseling and referral for patients with substance use disorders, the integration of prehospital buprenorphine represents a relatively novel clinical intervention. A pilot in Camden, N.J., is the first known example of the implementation of prehospital buprenorphine within a United States EMS system.6
This urban pilot program utilized a high-dose induction protocol and emphasized rapid referral to outpatient treatment with the explicit aim of facilitating next-day enrollment for long-term care. Early reports from this initiative demonstrated favorable, albeit primarily anecdotal, outcomes.
Following the success of the Camden protocol, additional EMS systems have adopted similar approaches.
Notably, in 2022, Delaware implemented a statewide protocol authorizing paramedics to administer buprenorphine in the prehospital setting.7 Evaluation of this program demonstrated that prehospital buprenorphine administration can be performed safely with a low incidence of adverse events, including precipitated withdrawal.
Despite these promising developments, the literature identifies several operational and systemic barriers to implementation. These include increased on-scene time, variability in EMS clinician attitudes toward patients with opioid use disorder, conflict in protocol interpretation between prehospital clinicians and emergency physicians, and persistent regulatory constraints.8-11
Such challenges underscore the complexity of integrating medication for opioid use disorder (MOUD) into traditional EMS settings. Programs that have demonstrated relative success are those that proactively address these barriers and nest prehospital buprenorphine within a bundle of care.
Importantly, prehospital initiation should not be viewed as a standalone intervention, but rather as a critical entry point into long-term treatment pathways. Strong evidence demonstrating improved long-term patient outcomes remains limited, reflecting the relative novelty of this intervention, wide diversity in program/protocol design, and limited data availability.
Nevertheless, when supported by comprehensive stakeholder training and integrated with wraparound services, prehospital buprenorphine programs represent a promising strategy for acute stabilization and may enhance connection to definitive, long-term treatment for patients with opioid use disorder.
Program Implementation & Operations
Implementation of the PREVENT program began with agency leadership participation in a full-day symposium launching the PREVENT learning collaborative. This symposium convened EMS agencies, social service organizations, emergency department personnel, and other community stakeholders to introduce the program within the broader context of the opioid epidemic.
It provided foundational knowledge regarding the evolving epidemiology of OUD, harm reduction strategies, current treatment interventions, and the structure of the PREVENT intervention model.
PREVENT was presented as a three-pronged approach to the management of opioid withdrawal. Eligible patients include those experiencing acute withdrawal following naloxone-reversed overdose, as well as individuals in abstinence-related withdrawal, provided that opioid withdrawal is the primary presenting condition.
In cases where competing acute medical conditions exist, EMS clinicians are directed to prioritize those conditions. When eligibility criteria are met, the PREVENT bundle includes:
- point-of-withdrawal EMS-based counseling
- referral to medication-assisted treatment (MAT) and/or peer recovery services
- prehospital administration of buprenorphine
Patients may engage in any combination of these services, with no requirement to participate in all components. Notably, participation does not require transport to a hospital.
At the time of implementation, prehospital buprenorphine administration required real-time medical consultation. Following the initial symposium, the learning collaborative continued through monthly multidisciplinary meetings, facilitating an ongoing exchange of information and collaborative problem-solving during program rollout.
Simultaneously, the agency made necessary administrative and operational preparations and obtained variances from the State EMS Office to incorporate buprenorphine into its formulary and to allow Advanced Emergency Medical Technicians (AEMTs) to become PREVENT-credentialed providers. This introduced operational challenges related to controlled substance management, which were addressed through the installation of dedicated controlled substance safes on ambulances supplied by the PREVENT program.
With expanded medication access among non-paramedic providers, the agency revised its controlled substance standard operating procedures and implemented targeted training for AEMTs, focusing on medication storage, tracking, handling, and documentation.
The agency also established referral partnerships with a MAT provider and a peer recovery organization. Integration with the electronic health record system enabled direct referral transmission to these partner organizations, facilitating continuity of care.
Provided credentialing followed regulatory approval, equipment installation, and the completion of controlled substance training requirements; training included five hours of online education and two hours of in-person instruction. Curriculum components included the epidemiology of OUD, principles of addiction medicine, stigma reduction, motivational interviewing, and protocol-specific training for PREVENT implementation and documentation.
In December 2025, the agency officially launched PREVENT services, with continued support from PREVENT leadership.
Implementation was largely successful, attributable in part to groundwork established by early adopting agencies, particularly the Burlington Fire Department (VT). Prior pilot experience helped resolve key logistical challenges, including medication supply chain issues, identification of referral partners, controlled substance management across provider levels, and regulatory considerations related to AEMT scope expansion.
Evaluating Early Outcomes: Successes and Hurdles
Program outcomes have been favorable from both provider and patient perspectives. Initial provider hesitancy was observed, largely reflecting a narrow focus on buprenorphine administration rather than recognition of PREVENT as a comprehensive care model.
Agency leadership addressed this through targeted education, emphasizing the value of counseling and referral as integral components of the intervention.
Since implementation, providers have reported multiple meaningful patient interactions, particularly through point-of-withdrawal counseling. These encounters have enhanced provider engagement and expanded awareness of available treatment re
To date, the agency has identified two clinical opportunities for buprenorphine administration, though neither resulted in medication delivery. The first case involved a 54-year-old female experiencing abstinence-related withdrawal after missing five days of prescribed buprenorphine due to transportation barriers.
This opportunity was missed due to a lack of awareness among providers regarding updated inclusion criteria. The patient was subsequently transported to the emergency department, where buprenorphine was administered and the patient was reconnected with long-term treatment.
The second case involved a similar patient presentation, with an AEMT crew initiating medical consultation for buprenorphine administration. Despite meeting withdrawal criteria (Clinical Opiate Withdrawal Scale score of 11), authorization was denied due to concerns regarding active vomiting and the potential for medication intolerance.
Subsequent review identified miscommunication between the field crew and medical control, as well as limited familiarity with updated protocol criteria. Additionally, the patient had recent methadone use, representing a contraindication under current guidelines.
Beyond these cases, PREVENT-credentialed providers have demonstrated increased awareness of OUD and available treatment pathways, including improved familiarity with emergency department-based MAT initiation programs and local peer recovery services. Collectively, these developments have strengthened the agency’s role as an integrated partner in efforts to reduce opioid-related morbidity and mortality.
Practical Takeaways
The successful implementation of the PREVENT program within a small EMS agency demonstrates the feasibility of introducing prehospital buprenorphine in rel partners.
Implementation success was driven by a comprehensive state-led support system, protocol flexibility, and targeted training of paramedics and Advanced EMTs. These findings suggest that state-led models may be particularly effective in enabling smaller or rural agencies to adopt novel clinical interventions.
Importantly, prehospital buprenorphine should be nested into a comprehensive prehospital bundle of care, with robust integration of wraparound services such as medication-assisted treatment programs and peer recovery res a primary, rather than a referral, point of care for patients with opioid use disorder.
Regulatory considerations, including formulary approval and scope-of-practice limitations for controlled substances, represent additional implementation barriers and underscore the importance of early engagement with medical direction and regulatory authorities.
Finally, program success is contingent upon addressing clinician-level factors, including stigma and bias toward individuals with opioid use disorder. Collectively, these findings highlight that while prehospital buprenorphine is operationally feasible, its effectiveness is dependent on system-level integration, regulatory alignment, and cultural readiness within EMS agencies.
Redefining Success in Prehospital OUD Care
For EMS agencies implementing prehospital buprenorphine programs, it is essential to define success beyond medication administration alone. Success should instead be framed as meeting patients where they are and engaging them in a respectful, patient-centered manner.
An encounter with a patient in opioid withdrawal can be considered successful even if the patient declines transport, referral services, or medication. Positive, stigma-free interactions help build trust and maintain an open door for future engagement. In many cases, the impact of these encounters may not be immediate, but they create the conditions for patients to seek help when they are ready.
In short, if not now, then perhaps later.
More from JEMS
EMS Personnel’s Perspectives on Buprenorphine for Opioid Use Disorder
Mobile Integrated Health Significantly Reduces Opioid-Related Deaths
The COVID-19 Pandemic’s Effects on the Opioid Epidemic
Leveraging a State Board of Health for Pilot Programs
References
1. U.S. Centers for Disease Control and Prevention. (2025, June 9). Understanding the opioid overdose epidemic. https://www.cdc.gov/overdose-prevention/about/understanding-the-opioid-overdose-epidemic.html
2. Saunders, H., Panchal, N., & Rudowitz, R. (2026, February 24). Opioid overdose deaths: National trends and variation by demographics and states. KFF. https://www.kff.org/mental-health/opioid-overdose-deaths-national-trends-and-variation-by-demographics-and-states/
3. WCAX. (2024, November 16). Burlington Fire Dept. becomes first in nation to launch “PREVENT” opioid initiative [Television broadcast]. South Burlington, VT: WCAX. https://www.wcax.com/2024/11/16/burlington-fire-dept-becomes-first-nation-launch-new-opioid-initiative/
4. City of Burlington. (2025, January 9). PREVENT initiative community safety forum [Presentation]. https://www.burlingtonvt.gov/DocumentCenter/View/7613/010925-Prevent-Initiative-Community-Safety-Forum-
5. U.S. Census Bureau. (2024 July 1). QuickFacts: Shelburne town, Chittenden County, Vermont. https://www.census.gov/quickfacts/fact/table/shelburnetownchittendencountyvermont/SBO030222
6. Carroll, G.G., Wasserman, D.D., Shah, A.A., Salzman, M.S., Baston, K.E., Rohrbach, R.A., Jones, I.L., & Haroz, R. (2021). Buprenorphine Field Initiation of ReScue Treatment by Emergency Medical Services (Bupe FIRST EMS): A Case Series. Prehospital Emergency Care, 25(2), 289–293.
7. Wanner, G.K., Dworkin, M., & Rosenbaum, R.A. (2025). Statewide Prehospital Buprenorphine in Delaware: Two-Years of Paramedic-Initiated Medication for Opioid Use Disorder After Overdose. Delaware journal of public health, 11(3), 24–28.
8. Denton, E.E., & Ventura, C.A.I. (2025). Prehospital Use of Medication-Assisted Treatment for Opioid Use Disorder: A Rapid Review of Implementation Approaches and Outcomes. Substance abuse and rehabilitation, 16, 55–69.
9. Wampler, W.R., Gormley, M.A., Griffin, S.F., Correa Ibarra, J., Bailes IV, P., Schwerin, D. L., Queen, K., Jones, K., Floyd, S. B., Beltran, G. W., Litwin, A. H., & Moschella, P. (2025). EMS Clinician Perceptions on Prehospital Buprenorphine Administration Programs. Prehospital emergency care, 29(4), 501–509.
10. Bailes IV, P., Gormley, M. A., Floyd, S. B., Wampler, W. R., Beltran, G.W., Estes, L., Litwin, A.H., & Moschella, P. (2025). Barriers to Buprenorphine: A Case Series of Misadventures Implementing a Prehospital Buprenorphine Protocol. Prehospital Emergency Care, 29(4), 420–426.
11. Davis, C. S., Carr, D. H., Glenn, M. J., & Samuels, E. A. (2021). Legal Authority for Emergency Medical Services to Increase Access to Buprenorphine Treatment for Opioid Use Disorder. Annals of emergency medicine, 78(1), 102–108.
