Written by Elizabeth Cairns, Mobilize Recovery Special Projects and Michael Masiowski, MD, reviewed by Code Recover Clinician Advisors, August 2026

Introduction

Opioid use disorder (OUD) patients deserve care for their chronic illness just as any other patient with a medical condition does. A patient who presents with a non-fatal overdose at the ED remains at high risk of subsequent overdose and death within three months. Yet a single ED-based intervention changes that trajectory: starting buprenorphine in the ED more than doubles the likelihood that a patient is still engaged in treatment 30 days later — 78%, compared to 37% for a referral alone. (source)  Connection to ongoing care via a peer navigator extends this benefit even further. The standard of care has changed — evidence shows that best practices now include medication, peer navigation, overdose prevention practices, and connection to ongoing care.

EDs are not currently reaching OUD patients effectively, but they have an enormous opportunity to do so. Nearly two-thirds of people who die of an overdose — 64.7% — visited an emergency department in the year before their death. (source) Yet statistics on MOUD induction and peer connection usage remain low.

Across 300 emergency departments participating in ACEP's Emergency Quality Network, among patients not already on medication, MOUD was started in only about 7% (source); across three urban academic EDs, 69% of patients presenting in opioid withdrawal received MOUD, compared to 6% of patients treated after an overdose. (source) The patients at highest risk are the least likely to be treated effectively, and the cost is measurable. In British Columbia, 19% of people who visited an ED after an overdose left against medical advice, and 9% of those experienced another overdose within one week. (source)

Emergency medicine universally accepted the massive infrastructure and financial cost of building 'Stroke Centers' because a “number needed to treat” (NNT) of 17 to 1 is considered an incredible, lifesaving victory in medicine. By comparison, initiating medications for opioid use disorder in emergency departments has an NNT of 2 to 1 for 30-day care retention. It is one of the most clinically efficient and highest-yield protocols an emergency room can possibly deploy. (source)

Peer navigators with lived experience act as liaisons between the patient and the clinical team, easing patient fears and increasing the likelihood they will engage in treatment, increasing patient satisfaction, and decreasing the likelihood of the patient leaving AMA (against medical advice).

For many patients, this ED visit is the only contact they will have with the medical system before their next overdose. That reality is the reason this protocol exists: it treats a Code Recover activation with the same urgency, speed, and clinical rigor as a stroke or cardiac code, rather than leaving a life-threatening condition to wait on a patient's readiness or a clinician's judgment about what they deserve.

Code Recover Protocol

I. Purpose

To establish a standardized, rapid-response, low-barrier protocol for patients in the Emergency Department (ED) with opioid use disorder (OUD). The "Code Recover" objective is immediate stabilization of the patient, appropriate introduction of medication for opioid use disorder (MOUD), overdose prevention, and a "warm handoff" facilitated by peers/substance use navigators to reduce mortality.

To recognize the importance and impact that peers have related to the success of OUD patients in the ED, including improved patient outcomes and reduced provider work load.

To implement research-driven best practices and standard of care for a cohort of patients that typically receive less than optimal care, and, given that non-fatal overdose OUD patients have the highest risk of overdose death post-discharge, to ensure that the entire care team is engaged to reduce that risk.

II. Activation Criteria

A "Code Recover" should be activated immediately—regardless of the primary complaint—if the patient meets any of the following:

• Post-Overdose: Patient has received naloxone or is recovering from opioid-induced respiratory depression. This includes pre-hospital or home administration.
• Active Withdrawal: Patient displays clinical signs of withdrawal (COWS score ≥ 8).
• Request for Help: Patient self-identifies as having OUD and expresses a desire to start treatment or manage cravings.
• Clinical Suspicion: Clinician identifies high-risk markers (e.g., frequent skin/soft tissue infections, frequent ED visits for pain or medication, endocarditis, or multiple past overdoses).
• EMS identification: EMS reports any of the above criteria.

III. The Code Recover Team

• ED Clinician/Advanced Practice Provider (APP): Leads medical management; stabilizes patient, orders buprenorphine per established protocols. Performs COWS assessment.
• Primary Nurse: Performs rapid COWS assessment; administers MOUD and adjunctive medication for patient comfort
• Peer Recovery Specialist: Provides person-to-person support with lived experience, uses motivational interviewing, conducts brief transition-focused assessment, coordinates follow-up care (transportation, medications, office visit, community resources)
• EMS personnel if applicable

IV. Code Recover Procedure

1. Rapid Assessment & Medical Stabilization

• Assess for Withdrawal: Use the COWS scale.
• Address Immediate Needs: Treat nausea, pain, or dehydration.
• Comfort Meds: If buprenorphine is delayed, consider adjunctive treatments (e.g., Ondansetron for nausea, Ibuprofen/Acetaminophen for aches, Clonidine for autonomic symptoms).
• Peer introduction: As soon as a peer is available, have them engage the patient and provide person-to-person emotional care and advocacy.

2. Buprenorphine Quick Start

• Threshold: Start induction when COWS ≥ 8 (moderate withdrawal).
• Initial Dose: Administer 8–16 mg of sublingual (SL) buprenorphine. Note: In fentanyl-prevalent areas, an initial 16 mg dose is increasingly preferred to rapidly occupy receptors. See quick-start guide. 
• Re-assessment: Evaluate at  30 minutes. If the patient remains in withdrawal, administer an additional 8–16 mg SL.
• Max Day 1 Dose: Up to 32 mg SL may be administered in the ED for rapid stabilization.
• If NOT in Withdrawal: If COWS < 8, do not administer in the ED. Provide the patient with a "Home Start" kit (prescription and instructions) and a Peer handoff. See home-start guide. 

3. Overdose Prevention & Connection

• Naloxone Distribution: Naloxone kits should be given to all Code Recover patients at discharge, and education provided to patients, family, significant others. Offer fentanyl test strips if available.
• Follow up and connection to ongoing care: The Peer Recovery Specialist makes contact with the patient and secures a confirmed follow up appointment with continuing care within 24–72 hours. 

V. Disposition & Discharge

• Bridge Prescription: Provide a 3–7 day supply of buprenorphine (typically 16 mg/day) to ensure no gap in treatment before the outpatient appointment.
• Pharmacy Verification: The peer should try to confirm the patient’s preferred pharmacy stocks buprenorphine. Provide home medications if necessary. Inquire about patient’s ability to afford the medication and troubleshoot any issues.
• Continuing Care: The Peer Recovery Specialist should text or call the patient within 24 hours of discharge to troubleshoot barriers (e.g., pharmacy issues, transportation, family support, work issues).
• CA Bridge Sample Discharge Instructions

VI. Documentation (Billing & Registry)

• ICD diagnostic codes are complex; providers typically use an F11 code (opioid-related disorders) or a T40 code depending on the circumstance. See Coding and Billing article.
• CPT Codes document time spent on interventions. Common codes used in these circumstances include:
  • SBIRT: CPT 99408 for 15-30 minutes, CPT 99409 for 30+ minutes, CMS G0396 – use these for time spent on motivational interviewing or peer coordination
  • OUD Treatment and Referral: CMS G2213 – this code is ED-specific and covers initiation of MOUD plus assessment, referral, and access to support. Use this code for initiation of MOUD and time spent with peers.
  • High complexity: CPT 99285 covers overdose reversal and comorbidity
  • Critical care: CPT 99291 covers risk to life or bodily function
• Some states have a specific code for peer support services. Documenting time spent is critical for use of these codes. 

VII. Outcomes

Programs implementing this model have been associated with improvements such as:

• Reduced rates of patients leaving against medical advice
• Higher patient satisfaction
• Reduced ED crowding and return visits