Preparing Emergency Medical Services for Prehospital Buprenorphine: Examining a Train-the-Trainer Approach to Strengthening the Overdose Chain of Survival

Objectives Opioid-related overdoses remain the leading cause of accidental death in the US. Many jurisdictions are exploring emergency medical services (EMS)-initiated prehospital buprenorphine induction at overdose scenes to reduce subsequent risk. This study evaluated a training strategy preparing EMS agencies to implement these protocols by examining barriers and facilitators affecting their readiness to integrate buprenorphine into standard care. Methods Leadership from 6 Missouri EMS agencies participated in a 6-month training program to support prehospital buprenorphine implementation. We described this evidence-informed frame-and-foster training approach and present findings from a readiness checklist and interviews with 8 trainees. Analysis followed a deductive, exploration, preparation, implementation, sustainment (EPIS)-guided framework approach to assess trainees' perceptions of the training and inner and outer barriers and facilitators to agency-wide implementation. Results All agencies reported readiness, with (1) frontline staff training and (2) partnering with peer-linkage programs as areas for further preparation. Training increased confidence and clarified workflows. Remaining inner barriers within EMS agencies included stigma among paramedics toward people who use drugs, staff resistance, and burnout, while facilitators included clear protocols and integration into community paramedicine programs. Outer barriers included inconsistent community buprenorphine availability, while facilitators included continued training and state support. Conclusions This evaluation provides early insights into how a structured training strategy can prepare EMS agencies to implement prehospital buprenorphine. Findings can inform future policy and practice to ensure EMS can effectively incorporate buprenorphine induction into overdose response and improve patient outcomes.