Everything we know about treating opioid addiction needs to change because of the spread of illegally made fentanyl. This extremely strong synthetic opioid is now behind most overdose deaths. Addiction to fentanyl brings serious dangers and makes treatment very hard.
Medicines like Suboxone that contain buprenorphine are proven to treat opioid addiction. But switching people hooked on fentanyl to buprenorphine therapy can be tricky and lead to problems. Fentanyl's unique lipophilic (fat loving) quality is a double edge sword. This allows fentanyl to act quickly but then hang around for weeks, slowly being released out of the body's fat cells. This makes starting Suboxone for fentanyl addiction difficult and a big risk for causing a precipitated withdrawal.
This guide looks closely at the risks of fentanyl addiction, how buprenorphine medicine works, and why fentanyl addiction makes standard buprenorphine dosage rules complicated. It explores better strategies clinicians are using to successfully move more fentanyl-addicted patients onto buprenorphine. The goal is to share knowledge, open up access to Suboxone, while reducing patient suffering and dropout. In a future blog post, I will share 2 Suboxone induction protocols that work.
The Rising Tide of Fentanyl Addiction and Overdoses
The current opioid epidemic spreading across America has been fueled by a surge in the illicit synthetic opioid fentanyl. Originally developed for medical use, this highly potent medication quickly found its way onto the streets.
Fentanyl is now often manufactured covertly and trafficked into the U.S. from abroad. It is commonly mixed into supplies of heroin, pressed into counterfeit pills, or sold misleadingly as heroin.
This widespread fentanyl contamination of the illicit drug supply has driven alarming surges in overdose deaths since 2013. The CDC estimates that over 150 Americans die every day from overdoses involving synthetic opioids like fentanyl. From 2019 to 2020, overdose deaths jumped 30% to a historic 93,000.
But the numbers only begin to capture fentanyl's deadly toll. Thousands more struggle daily with severe fentanyl addiction, facing compulsive use, financial ruin, destroyed relationships, criminal acts, and the constant threat of overdose.
Getting patients with fentanyl addiction into treatment is paramount. Yet complexities surrounding fentanyl make providing that treatment more difficult. Understanding why begins with examining how fentanyl works in the brain.
What Makes Fentanyl So Dangerous and Addictive?
Fentanyl is an incredibly powerful synthetic opioid that is far more potent than morphine or heroin.
Some key factors that increase its risks include:
High potency: Fentanyl is around 50-100 times stronger than morphine in terms of analgesic effects. Even tiny amounts can be lethal. This makes precise dosing difficult with illicitly manufactured versions.
Fast onset: Being highly lipophilic, fentanyl crosses the blood-brain barrier far more rapidly than other opioids. Users describe an intense "rush" that drives repeated use.
Short duration: While fast-acting, fentanyl's effects wear off quickly as it redistributes from the brain into the body. This further escalates patterns of compulsive redosing.
Euphoric high: Fentanyl causes a rush of dopamine to the brain's reward system, giving a pleasurable high that reshapes this circuitry and leads to addiction.
Painkiller effects: Like other opioids, fentanyl attaches to mu-opioid receptors all through the body and brain, switching on pain relief through different routes.
Severe withdrawal: Discontinuing fentanyl after regular use leads to intensely unpleasant opioid withdrawal symptoms, perpetuating dependence.
In short, fentanyl provides an extremely potent high that addicts people almost immediately. But it comes with massive risks that addicts often discount until it's too late.
The Difficulties of Treating Fentanyl Addiction
The unique pharmacological properties of illicit fentanyl make treating addiction to the drug complex:
Abstinence is challenging: Due to fentanyl’s short duration of action, compulsive redosing becomes ingrained. The early phase of treatment often focuses on managing withdrawal symptoms through medical stabilization.
Withdrawal lasts longer: Various factors likely prolong fentanyl withdrawal compared to other opioids. Post-acute withdrawal syndrome (PAWS) may persist for weeks or months. Relapse risk remains high long into recovery.
Higher overdose risk: Those with a fentanyl addiction have lost their tolerance to other opioids but still crave the intense euphoric effects. This population faces astronomically high overdose risks after even brief periods of abstinence. Overdose precautions, such as naloxone, are imperative.
Polysubstance use: Other substances like cocaine and methamphetamine are increasingly mixed with fentanyl. Managing addictions to multiple drugs together is often required with treatment.
Mental health comorbidity: Underlying mood disorders, trauma, and other mental illnesses commonly co-occur with fentanyl addiction. Integrated psychiatric treatment is ideal but not always available.
These factors surrounding fentanyl use make treating addiction especially complicated. But evidence-based medications like buprenorphine are a vital tool if they can be implemented correctly.
How Does Suboxone Treat Opioid Addiction?
Prescription medications that activate opioid receptors in the brain can provide relief from drug cravings. They also ease withdrawal while blocking the effects of illicit opioids. This helps stabilize patients in recovery while addressing the underlying brain disruptions that perpetuate addiction.
Buprenorphine stands as one of our most potent and thoroughly researched medications employed to treat opioid use disorder. It is formulated together with the opioid-blocking agent naloxone in the medicine Suboxone.
When taken regularly at a therapeutic dose, buprenorphine:
Activates opioid receptors enough to reduce drug cravings and prevent withdrawal symptoms
Provides less euphoria than full opioid agonists, minimizing misuse potential
Displaces other opioids from receptors due to higher binding affinity
Blocks effects of illicit opioids if they are taken
Carries lower risks of respiratory depression and overdose death
This allows buprenorphine to curb opioid addiction on two fronts - easing withdrawal while blocking the rewarding euphoric effects. By managing symptoms, it can help patients fully engage in counseling, community support, and behavioral changes.
Challenges of Transitioning Patients to Suboxone or Buprenorphine to Treat Fentanyl Addiction.
Everything about buprenorphine makes it perfect for treating addictions involving all types of opioids. However, buprenorphine was well studied on heroin and typical oral opioids, not fentanyl. Transitioning patients from fentanyl and other potent synthetic opioids to buprenorphine has been difficult.
The higher potency and binding strength of fentanyl at opioid receptors makes displacement by buprenorphine much more likely to trigger precipitated withdrawal. Multiple factors contribute:
Fentanyl has a higher binding affinity than buprenorphine at mu-opioid receptors. Buprenorphine must fully displace all bound fentanyl to prevent withdrawal.
With repeated or sustained exposure, fentanyl accumulates and is slowly released from fat cells and peripheral tissues for extended periods.
Even after cessation of use, trace fentanyl continues occupying receptors, ready to trigger withdrawal if activated by buprenorphine.
Patients exhibit wide variability in clearing the body's accumulated fentanyl depending on frequency and severity of use. This makes timing the start of buprenorphine hard to predict.
Precipitated opioid withdrawal involves sudden, severe withdrawal symptoms starting within minutes to hours of the first buprenorphine dose. This suffering risks patients abandoning treatment at the most vulnerable early stage. New protocols are needed.
Data on Precipitated Withdrawal with Fentanyl Transitions to Buprenorphine
Limited data exists so far on rates of precipitated opioid withdrawal when transitioning real-world patients from fentanyl specifically to buprenorphine treatment. But early research indicates it is extremely common using traditional induction methods:
A 2020 case series found that buprenorphine triggered severe withdrawal in 2 out of 4 consecutive patients who tested positive for fentanyl use shortly before induction.
In a 2019 study of 63 heroin users, around one-third reported experiencing precipitated withdrawal from buprenorphine when they had unknowingly used fentanyl-contaminated heroin.
A 2020 literature review examined opioid withdrawal symptoms among 57 patients transitioned from fentanyl and other opioids (like methadone) using newer “microdosing” protocols. 3 patients still experienced precipitated withdrawal, all from higher dose methadone transitions.
While more rigorous studies are needed, these initial data points illustrate that current buprenorphine induction methods fail a high proportion of patients transitioning from fentanyl use. This urgently calls for protocols optimized specifically for fentanyl addiction.
Improved Approaches to Starting Buprenorphine Therapy in Fentanyl Users
Various strategies show promise in smoothing the transition process for those who want to use Suboxone or Buprenorphine to Treat Fentanyl Addiction:
Longer wait times: Extending the window between last fentanyl use and first buprenorphine dose allows more clearance time. You must wait at least 48 hours. This requires medical supervision to manage ongoing withdrawal.
Lower starting doses: Micro-dosing protocols use initial buprenorphine doses of 0.2-0.5 mg compared to typical 2-4mg starting doses. This reduces likelihood of precipitated withdrawal.
Symptom monitoring: Carefully evaluating objective signs and subjective symptoms of withdrawal prior to dosing and in between doses can guide pace and adjustments.
Slower titrations: After starting with micro-doses, buprenorphine is increased gradually over 5-7 days or longer, allowing it to slowly displace fentanyl.
Adjunct medications: Clonidine, non-steroidal anti-inflammatories, and other comfort medications help manage the transition process.
Supervised setting: Induction and stabilization ideally occurs in a supervised medical setting where withdrawal can be handled safely if precipitated.
Patient education: Setting patient expectations and having a plan helps retain patients in treatment if they experience some discomfort during transition.
With harm reduction principles in mind, the goal is to retain patients in treatment using patient-centered protocols that minimize suffering. A poorly managed induction can otherwise lead to shame, loss of trust, and abandonment of care. More research is still urgently needed to provide evidence-based protocols.
Keys to Success When Transitioning Fentanyl Users to Buprenorphine
Trying to overcome fentanyl addiction is an immense challenge. But with patient-provider collaboration, buprenorphine induction and treatment can still be successful using some key principles:
Motivation to get well and understanding that discomfort is temporary
Patience and willingness to adjust protocols based on response
Extended wait times for fentanyl to clear before starting buprenorphine. Wait at least 48 hours.
Starting with micro doses of buprenorphine and titrating up slowly
Close monitoring and management of withdrawal and medication effects
Seamless transition to maintenance therapy and psychosocial interventions
Ongoing medical management of cravings, side effects, and relapse risks
With care and attention, patients addicted to fentanyl can still benefit from buprenorphine treatment. While induction brings unique risks, they can be anticipated and managed with the right clinical expertise and social support. Removing barriers to buprenorphine access remains imperative to turning the tide on the overdose crisis.
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Key Takeaways on Buprenorphine Treatment for Fentanyl Addiction
Illicit fentanyl is fueling surging opioid overdose deaths across America. Addiction poses serious risks.
Fentanyl has distinct pharmacologic properties - high potency, rapid onset, and protracted clearance - that drive addiction and complicate treatment.
Transitioning fentanyl users onto buprenorphine medication frequently causes precipitated opioid withdrawal with standard induction protocols.
Emerging microdosing strategies involving lower starting doses, slower titration, and longer wait times show promise in reducing complications.
Successfully transitioning fentanyl-addicted patients onto buprenorphine requires expertise, close monitoring, individualization, and patient engagement.
Improving access to buprenorphine treatment for fentanyl addiction must remain a priority amid this public health crisis.
Overcoming addiction is never easy, and fentanyl has presented new hurdles. But a better scientific understanding of fentanyl and refined clinical strategies will help more patients begin potentially life-saving treatment with buprenorphine. There are always paths forward, even from the darkest places.
Starting Suboxone for Fentanyl Addiction - FAQ
1. What is Suboxone and how is it used to treat opioid addiction?
Suboxone - a combo med containing buprenorphine and naloxone. Dissolves under tongue. Blunts opioid cravings, stops withdrawal. Lets people recover without going cold turkey. Crucial help for fighting addiction.
2. How does Suboxone help in the treatment of opioid addiction?
With the right dose, consider it smooth sailing, no harsh ups and downs. Stabilizes mood and motivation. Keeps withdrawals at bay so you can focus on getting well. You build better habits over time.
3. Can Suboxone be prescribed for all types of opioid addiction?
Helps many opioid addictions - fentanyl, oxy, hydrocodone, heroin. But treatment plans are unique depending on the situation. Provider assesses your needs and history. There are no cookie-cutter options in addiction care.
4. How does Suboxone differ from methadone?
Both curb withdrawal and cravings. But Suboxone is partial opioid agonist, methadone is a full agonist. Suboxone is flexible - prescribed at doctor's office. Methadone require daily visits at a clinic. Pros and cons to each. Work with doctor to choose best option.
5. What are the common withdrawal symptoms associated with fentanyl addiction?
Fentanyl's grip is fierce. Letting go means misery - vomiting, diarrhea, crushing depression and anxiety. Bone-deep aches. There is no peace with fentanyl withdrawal. Expect Post Acute Withdrawal Syndrome for up to 2 years.
6. How is precipitated withdrawal prevented when starting Suboxone?
Timing is vital. Opioid receptors must open up before starting Suboxone. If taken too soon, intense sudden withdrawal will occur. Wait for moderate opioid withdrawal to begin naturally. Then receptors are ready for smooth transition. In a future blog, I will share my protocol in a future blog post.
7. Can Suboxone help prevent overdose in individuals with opioid addiction?
Suboxone calms the agonizing urge to use fentanyl or other opioids. It stops the ceaseless craving that demands that you use drugs at any cost. Stopping drugs saves lives.
This article is for informational purposes only and not a substitute for medical advice. Discuss any major treatment decisions with a healthcare professional specializing in addiction medicine.
About the author:
Dr. Harold Pierre is a board-certified anesthesiologist and addiction medicine specialist with over 20 years of experience. He is board-certified by the American Board of Anesthesiology and the American Board of Preventive Medicine.
This website is provided for educational and informational purposes only and does not constitute providing medical advice or professional services. The information provided should not be used for diagnosing or treating a health problem or disease, and those seeking personal medical advice should consult with a licensed physician or another qualified medical professional. Never disregard professional medical advice or delay in seeking it because of something you have read on this website.
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