ASAM Clinical Considerations: Buprenorphine Treatment of Opioid Use Disorder for Individuals Using High-potency Synthetic Opioids

Abstract

Treatment of opioid use disorder (OUD) with buprenorphine has evolved considerably in the last decade as the scale of the OUD epidemic has increased along with the emergence of high-potency synthetic opioids (HPSOs) and stimulants in the drug supply. These changes have outpaced the development of prospective research, so a clinical consideration document based on expert consensus is needed to address pressing clinical questions. This clinical considerations document is based on a narrative literature review and expert consensus and will specifically address considerations for changes to the clinical practice of treatment of OUD with buprenorphine for individuals using HPSO. An expert panel developed 6 key questions addressing buprenorphine initiation, stabilization, and long-term treatment for individuals with OUD exposed to HPSO in various treatment settings. Broadly, the clinical considerations suggest that individualized strategies for buprenorphine initiation may be needed. The experience of opioid withdrawal negatively impacts the success of buprenorphine treatment, and attention to its management before and during buprenorphine initiation should be proactively addressed. Buprenorphine dose and dosing frequency should be individualized based on patients’ treatment needs, the possibility of novel components in the drug supply should be considered during OUD treatment, and all forms of opioid agonist treatment should be offered and considered for patients. Together, these clinical considerations attempt to be responsive to the challenges and opportunities experienced by frontline clinicians using buprenorphine for the treatment of OUD in patients using HPSOs and highlight areas where prospective research is urgently needed.

Harm reduction in undergraduate and graduate medical education: a systematic scoping review

“…Include harm reduction principles in curricula -Of the 19 distinct curricula reviewed, only six report explicitly teaching harm reduction as a set of principles, theory, or framework -85% of the content taught falls on the introductory side of the Harm Reduction Educational Spectrum (HRES) developed by the authors, before the point where skill progression benefits from an understanding of harm reduction framework -Harm reduction principles offer the critical thinking skills foundational for understanding and applying more advanced harm reduction strategies -They emphasize the importance of other health principles necessary for working with PWUD [ 12 ] -They will help mitigate the lag in medical education that occurs when trying to characterize a fluctuating health crisis because instead of teaching students a set of static practices it encourages students to apply harm reduction as a framework 2. Include non-opioid (e.g., cocaine, psychostimulant, alcohol) related harm reduction -None of the reviewed curricula report discussing the importance of harm reduction for substances other than opioids -With rising rates of fentanyl adulteration in the unregulated drug supply [ 71 , 72 ], our trainees need to be prepared to discuss opioid-related harm reduction (e.g., overdose identification, naloxone) with patients who use any type of drug -Morbidity and mortality related to stimulant use has increased since 2014 [ 2 ] 3. Include more advanced harm reduction skills -Of all the discrete content topics taught across 19 distinct curricula, those that fell into the theme of Advanced Harm Reduction Skills (safer injection & fentanyl test strips) were only referenced 7 times; this amounts to 5% of curricula time -Ensures that trainees are provided with a full picture of harm reduction practices -Adds tools to trainee’s toolbox; trainees cannot practice these skills or refer patients to other locations where they can receive these services without knowing they exist 4.…”

“…-With rising rates of fentanyl adulteration in the unregulated drug supply [ 71 , 72 ], our trainees need to be prepared to discuss opioid-related harm reduction (e.g., overdose identification, naloxone) with patients who use any type of drug…”

Overview of best practices for buprenorphine initiation in the emergency department

“…First, a poorly regulated drug supply has resulted in an increased presence of potent synthetic analogs like fentanyl and nitazenes [ 68 – 70 ]. A growing body of qualitative and mixed methods literature has reported growing concern from both patients and practitioners that this evolving drug supply necessitates changes to buprenorphine initiation protocols [ 71 – 74 ]. Some postulate that PWS following buprenorphine initiation for people who use fentanyl can happen even after periods of abstinence greater than 24 hours, given fentanyl’s lipophilicity [ 75 , 76 ].…”

Open‐label investigation of rapid initiation of extended‐release buprenorphine in patients using fentanyl and fentanyl analogs

“…This literature is still evolving, but perhaps clinical practice will need to adopt more strict clinical trial-like procedures to achieve low rates of precipitated withdrawal, while this was not necessary in the prefentanyl era. The important message that can be taken from these trials and recent buprenorphine treatment guidelines 30,31 is that buprenorphine remains an effective drug for treatment of OUD, even for individuals using fentanyl and fentanyl analogues.…”