Buprenorphine Inductions: Options and Innovations

The presence of fentanyl and fentanyl analogues (F/FA) in the US drug supply has contributed to dramatic increases in overdose deaths, as well as new challenges in Medications for Opioid Use Disorder (MOUD) care. Inductions for patients using fentanyl present a higher risk of precipitated withdrawal as well as idiosyncratic reactions including dystonia and intractable vomiting. F/FA's high affinity binding, variable potency and unique impacts pose special challenges for MOUD inductions. Patients may give up on MOUD after an unsuccessful induction. These same difficulties may lead medical providers to limit the patients to whom they offer buprenorphine because of difficult experiences with inductions. Low dose induction is a viable alternative, though patients and withdrawal management programs often struggle with the length or complexity of this process. In this interactive workshop we will review the challenges of initiating buprenorphine for people who have been using fentanyl intentionally or unintentionally. We will present an overview of low dose induction and modifications to this process for outpatient services, and a new protocol using low and high-dose approaches for inpatient withdrawal management. After this workshop, participants will have an expanded set of tools to apply when supporting transitions onto buprenorphine for people who use fentanyl.