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

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This rapid clinical update reviews evolving inpatient management of opioid use disorder (OUD) in the fentanyl era, emphasizing that the illicit drug supply has largely shifted to high-potency synthetic opioids, driving higher overdose deaths and frequent polysubstance exposure. Major organizations (ASAM, SAMHSA, AAP, SAHM) affirm that medications for OUD (MOUD) are the gold standard; withdrawal management (“detox”) alone is not recommended. MOUD significantly reduces all-cause and overdose mortality, while mortality rises markedly after stopping treatment. Despite this, adolescents have reduced access to buprenorphine, highlighting ongoing stigma and system barriers.<br /><br />The session compares the three FDA-approved MOUD options: methadone (full agonist, dispensed only through federally regulated opioid treatment programs), buprenorphine (partial agonist, broadly prescribable with DEA registration; also treats pain), and naltrexone (antagonist; challenging to initiate due to required opioid-free interval, especially with fentanyl). Choice should be individualized—“the best MOUD is the one the patient will take.”<br /><br />A key focus is buprenorphine initiation strategies amid fentanyl’s lipophilicity and tissue “depots,” which increase risk of precipitated withdrawal if started too soon. Precipitated withdrawal presents abruptly with severe symptoms and high COWS scores and can deter future treatment. The most effective treatment is additional buprenorphine, often with rapid escalation (e.g., 24–32 mg on day 1) plus symptom-directed adjuncts (e.g., clonidine, antiemetics; sometimes benzodiazepines). Initiation approaches include standard induction (requires moderate withdrawal), high-dose induction (rapid stabilization, low reported precipitated withdrawal in ED cohorts), and low-dose “micro/overlap” induction with continued full-agonist opioids (often inpatient, useful for pain or methadone-to-buprenorphine transitions).<br /><br />The update also covers methadone logistics (slow titration to therapeutic doses, daily OTP visits; hospital use allowed but limited in SNFs), complicated withdrawal from adulterants (xylazine/medetomidine/unregulated benzodiazepines), and harm reduction (naloxone prescribing, fentanyl test strips). Stigma and undertreated pain contribute to AMA discharges; clinicians should use non-stigmatizing language and proactively treat withdrawal and pain.

Keywords

inpatient opioid use disorder management

fentanyl era opioid supply

medications for opioid use disorder (MOUD)

buprenorphine induction strategies

precipitated withdrawal treatment

high-dose buprenorphine initiation

low-dose microinduction overlap

methadone opioid treatment program logistics

naltrexone opioid-free interval challenge

harm reduction naloxone fentanyl test strips