Challenges with buprenorphine inductions in the context of the fentanyl overdose crisis: A case series

Abstract

Introduction and Aims. North America is currently experiencing an epidemic of opioid overdose deaths, driven by the proliferation of fentanyl in the street drug market. Although buprenorphine/naloxone (BUP/NX) is an evidence-based, first-line opioid agonist for the management of opioid use disorder, a key challenge in its prescribing lies in the fact that it can precipitate opioid withdrawal during its initial induction process. At this time, there is minimal literature on the BUP/NX induction process in individuals who use illicit fentanyl regularly. Design, Methods and Results. A case series from a Vancouver, Canada addiction medicine clinic of three fentanyl-exposed patients who experienced unexpected, precipitated withdrawal when initiating BUP/NX. Discussion and Conclusion. These cases describe incidents of precipitated opioid withdrawal occurring after unusually long periods of fentanyl abstention. Although fentanyl is experienced as a short-acting opioid, the drug persists much longer in the body's peripheral tissues. Here, we highlight the new challenges fentanyl may pose to current BUP/NX induction strategies, and explore the possibility of a long-acting pharmacokinetic effect of fentanyl in the setting of repeated illicit use. [Shearer D, Young S, Fairbairn N, Brar R. Challenges with buprenorphine inductions in the context of the fentanyl overdose crisis: A case series.

“Just give them a choice”: Patients' perspectives on starting medications for opioid use disorder in the ED

“…Participants noted an emerging issue with buprenorphine as the opioid supply is increasingly comprised of fentanyl rather than heroin—that people using fentanyl may have a higher risk of precipitated withdrawal despite a period of abstinence that was previously considered safe 39–42 . This is emerging in the literature as an important issue, as it makes both people with OUD and clinicians hesitant to initiate buprenorphine 39–42 .…”

“…Participants noted an emerging issue with buprenorphine as the opioid supply is increasingly comprised of fentanyl rather than heroin—that people using fentanyl may have a higher risk of precipitated withdrawal despite a period of abstinence that was previously considered safe 39–42 . This is emerging in the literature as an important issue, as it makes both people with OUD and clinicians hesitant to initiate buprenorphine 39–42 . Fortunately, research addressing the treatment of precipitated withdrawal is a rapidly evolving; “micro” and “macro” dosing of buprenorphine may be effective, and IV ketamine has also been used with good effect 43–47 .…”

“…safe. [39][40][41][42] This is emerging in the literature as an important issue, as it makes both people with OUD and clinicians hesitant to initiate buprenorphine. [39][40][41][42] Fortunately, research addressing the treatment of precipitated withdrawal is a rapidly evolving; "micro" and "macro" dosing of buprenorphine may be effective, and IV ketamine has also been used with good effect.…”

“…[39][40][41][42] This is emerging in the literature as an important issue, as it makes both people with OUD and clinicians hesitant to initiate buprenorphine. [39][40][41][42] Fortunately, research addressing the treatment of precipitated withdrawal is a rapidly evolving; "micro" and "macro" dosing of buprenorphine may be effective, and IV ketamine has also been used with good effect. [43][44][45][46][47] However, the actual risk of precipitated withdrawal for an individual patient is based on history of drug use (which drugs and when) and may be difficult for a clinician to predict.…”

The Community-Based Medication-First program for opioid use disorder: a hybrid implementation study protocol of a rapid access to buprenorphine program in Washington State

“…Fentanyl dependence can complicate buprenorphine starts and increase overdose rates and therefore may impact our intervention and outcomes. We will discuss the impacts of this potential confounding in our outcomes paper [ 32 , 35 ]. Additionally, there were no measures of fidelity for the CBMF program or systematic quantification of receipt of services by individual participant (e.g., to measure a dose–response effect).…”