Rapid Clinical Updates: Updates in Opiate Use Disorder: Advances in Therapies Across All Ages-Handout

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Illicit opioid use has shifted toward high‑potency synthetic opioids such as fentanyl, increasing overdose deaths and creating an urgent hospital “practice gap.” Hospitalists are now central to diagnosing and treating opioid use disorder (OUD) and expanding access to medications for OUD (MOUD), especially for adolescents who face major barriers to care. MOUD reduces mortality by about 50%, with particularly strong benefits for people who are incarcerated. A key recent finding is that mortality is about six times higher in the four weeks after MOUD is stopped, emphasizing the importance of continuation.<br /><br />Buprenorphine is a partial mu‑opioid receptor agonist that provides opioid effect without full agonist euphoria. However, traditional induction (2–8 mg initial dosing) can trigger precipitated withdrawal, especially with fentanyl because it is highly lipophilic and persists in the body. If precipitated withdrawal occurs, the most effective treatment is additional buprenorphine, rapidly escalating to 24–32 mg on the first day, along with symptom management using alpha‑agonists and sometimes benzodiazepines.<br /><br />Newer initiation strategies include “high‑dose” buprenorphine (starting 8–16 mg, quickly increasing to 16–32 mg in 1–2 doses, often stabilizing around 24 mg/day). Evidence suggests precipitated withdrawal is uncommon (about 1% after an 8 mg first dose in one ED study). Another approach is low‑dose buprenorphine initiation while continuing full‑agonist opioids over multiple days, best done inpatient, and useful for patients with pain transitioning from fentanyl or methadone; final targets with fentanyl often require 24–32 mg/day.<br /><br />Other OUD medications have limitations: naltrexone requires a longer opioid‑free interval and may raise overdose risk after discontinuation; methadone requires slow titration, reaches steady state in ~5 days, and effective OUD doses are often 100–200 mg/day, yet cravings may persist. Clinicians should also consider adulterants (e.g., medetomidine, xylazine, unregulated benzodiazepines) that complicate withdrawal; alpha‑agonists such as clonidine or dexmedetomidine may help.

Keywords

fentanyl

synthetic opioids

opioid use disorder (OUD)

medications for opioid use disorder (MOUD)

buprenorphine induction

precipitated withdrawal

high-dose buprenorphine initiation

low-dose buprenorphine microinduction

methadone titration

naltrexone discontinuation risk