Emergency department–initiated buprenorphine vs brief intervention for opioid use disorder: a systematic review and meta-analysis of clinical trials

Introduction Emergency departments (EDs) are critical points of contact for individuals at high risk, as opioid use disorder (OUD) remains a major public health crisis. While Screening, Brief Intervention, and Referral to Treatment (SBIRT) andother brief intervention (BI) models have been promoted as pragmatic approaches in acute care, their efficacy for OUD is uncertain. In contrast, ED-initiated buprenorphine (BUP) has shown promise for improving outcomes, but comparative trial data require synthesis.Methods Following PRISMA 2020 guidelines, we reviewed randomized and nonrandomized clinical trials comparing ED-initiated BUP with BI, referral, or usual care. Primary outcomes were treatment engagement and retention; secondary outcomes included opioid use, overdose risk behaviors, and healthcare utilization. Searches were conducted in PubMed, Scopus, Google Scholar, Web of Science, and trial registries through January 29, 2025. Risk of bias was assessed using ROB-2, and data were pooled via random-effects models.Findings Nine trials (n = 1,172), primarily from North America, met inclusion criteria. Compared with BI (52%), BUP initiation yielded higher adherence (61%) and lower opioid use prevalence (17% vs. 28%). Multiple RCTs consistently favored BUP for short-term engagement, whereas BI showed minimal effects on treatment utilization, overdose risk, or substance use outcomes. Considerable heterogeneity (I2 ≈ 99%) and potential publication bias were observed.Conclusion ED-initiated BUP is superior to BI for short-term treatment engagement and reducing opioid use, reinforcing its role as a frontline intervention in acute care. Nevertheless, high heterogeneity, short follow-up, and limited geographic scope constrain the evidence base, highlighting the need for broader and longer-term studies.