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Podcast Recap | The Curbsiders: Treating OUD in the Fentanyl Era with Dr. Melissa Weimer

November 9, 2023

In the midst of an opioid epidemic, including the widespread use of illicit fentanyl, evidence-based treatments are available and recovery is possible for patients suffering from opioid use disorder. In this episode of "The Curbsiders Addiction Medicine" podcast, Dr. Melissa Weimer of Yale University explains how to safely prescribe methadone and buprenorphine when treating this disease.

Podcast length: 55:22 minutes

Key Takeaways

1. Methadone and buprenorphine—capable of reducing mortality by as much as 50%—are clinicians' best options for evidence-based, life-saving treatments as the U.S. experiences an unprecedented overdose crisis, precipitated by fentanyl, fentanyl analogues, and other high-potency synthetic opioids (HPSOs).

2. To adapt to the new "fentanyl era," clinicians must make changes to how they previously initiated methadone and buprenorphine treatment in patients with substance use disorders while still emphasizing individualized treatment.

3. Clinicians shouldn't hesitate to consider utilizing methadone as a treatment option, even if that means working with addiction specialists and/or partnering with local opioid treatment programs.

• In a hospital-setting, rapid uptitration during methadone initiation can be done safely up to 60 mg/day in 2-3 days. One caution is that the long half-life of methadone can lead to dose stacking if done inappropriately: "Always remember you can always give more, but you can't give less," says Dr. Weimer.
• In a hospital setting, full agonist opioids can be used to treat opioid withdrawal to augment methadone uptitration or can be used alone in people not interested in medications for opioid use disorder (MOUD).
• Potential pitfalls include not considering use of methadone as a treatment option at all, giving a dose that's too low (in the 10 mg range) or conversely a dose that's too high that could result in dose stacking, or being overly concerned about QTc prolongation.
• In general, the first 72 to 96 hours of hospitalization for patients who've had lots of exposure to HPSOs can be difficult, so supportive strategies such as listening and empathizing with what patients are saying about their tolerance levels can go a long way.

4. Although the true incidence of buprenorphine-precipitated opioid withdrawal is still unknown, it's likely higher than it was before the introduction of HPSOs.

Dr. Weimer notes that in the past 5 years, she's seen an increase in patients who've been exposed to HPSOs having severe withdrawal symptoms after initiating buprenorphine. Illicit fentanyl, in particular, has a longer half-life. Such patients are typically taking low doses of buprenorphine and haven't had enough time away from fentanyl use, so they experience worsening withdrawal symptoms instead of improvement.

"We need to become more comfortable with someone who is in withdrawal, to treat their withdrawal. We know how to do that. Do not use the low doses; it’s not going to be sufficient for that person with HPSOs. It’s not going to sufficiently protect them from overdose. They are not going to continue on it because they don’t feel good. So that’s the opportunity to really quickly within the 5 to 10 minutes it takes for the medicine to dissolve in their mouth, to change their life," says Dr. Weimer.

The following are clinical considerations for using burpenorphine as a treatment option:

• High-dose buprenorphine initiations use doses of 8-16 mg after the onset of withdrawal symptoms to more rapidly improve symptoms and get to a therapeutic dose. A recent RCT found that less than 1% of individuals who received initial doses of buprenorphine 8 mg or greater had precipitated opioid withdrawal.
• Low-dose buprenorphine initiation can be used in appropriate clinical situations to minimize withdrawal symptoms.
• Higher doses of buprenorphine (up to 32 mg) or the use of long-acting injectable buprenorphine may be needed to stabilize patients with HPSO use.
• While there's sparse evidence on how to treat buprenorphine-precipitated opioid withdrawal, options include more buprenorphine, clonidine, and ketamine, and consideration of full agonist opioids and benzodiazepines in patients with ongoing symptoms. Dr. Weimer notes, "Of all the medicines I’ve used for precipitated withdrawal, the most effective medicine I’ve found is ketamine."

5. Now more than ever there's a need in the U.S. for more clinicians who can screen, address, and treat substance use and substance use disorders.

• Clinicians can become board certified in Addiction Medicine using the Practice Pathway. The practice pathway, available only until 2025, enables physicians to meet eligibility requirements for certification in addiction medicine without completing an ACGME-accredited fellowship in addiction medicine. Additional requirements include either minimum time in practice or completion of non-ACGME-accredited fellowship training in addiction medicine.
• After 2025, clinicians would need to complete an addiction medicine fellowship.

Any views, thoughts, and opinions expressed in this podcast recap are solely that of the host and guests and do not reflect the views, opinions, policies, or position of epocrates and athenahealth.

Source:

Chan, C. (2023, October 17). The Curbsiders Podcast. Addiction Medicine. #24 Treating OUD in the Fentanyl Era: ASAM Treatment Week with Dr. Melissa Weimer. https://thecurbsiders.com/curbsiders-podcast/24-treating-oud-in-the-fentanyl-era-asam-treatment-week-with-dr-melissa-weimer

Additional resources

• (Accessed 2023, November 8). Yale Program in Addiction Medicine. Resources for Safer Injection and Substance Use. https://safersubstanceuse.org/clinicians/
• Weimer M, et al. 2023, Nov-Dec; 17(6):632-639. J Addict Med. ASAM Clinical Considerations: Buprenorphine Treatment of Opioid Use Disorder for Individuals Using High-potency Synthetic Opioids. https://pubmed.ncbi.nlm.nih.gov/37934520/