Paramedic perspectives on prehospital buprenorphine: A qualitative case study of implementation in emergency medical services.

BACKGROUND: Medications for opioid use disorder reduce morbidity and mortality, yet treatment access remains limited. Prehospital buprenorphine administered by Emergency Medical Services is an emerging strategy to address this gap, but implementation remains limited. Understanding clinician perspectives during early implementation is critical to successful adoption. We explored paramedics' perspectives during early implementation of a prehospital buprenorphine program. METHODS: We conducted a qualitative embedded case study using semi-structured interviews with paramedics involved in encounters where buprenorphine was considered or administered. Interview transcripts were analyzed using a hybrid inductive/deductive codebook thematic analysis informed by systematic interview debriefings. Emergency Medical Services records were reviewed to contextualize interview data. RESULTS: Six paramedics were interviewed across encounters involving opioid overdose reversal and withdrawal management. Five themes emerged: (1) scene context and competing priorities; (2) perceived value of buprenorphine; (3) clinician comfort and exposure; (4) importance of follow-up; and (5) logistical and operational barriers. CONCLUSIONS: Prehospital buprenorphine was feasible and well tolerated, and paramedics described providing effective care. Uptake appeared influenced more by contextual, logistical, and system-level factors rather than clinical complexity. Addressing operational barriers, increasing exposure, and strengthening continuity of care may support broader implementation of prehospital buprenorphine programs.