Low Success Rates in Buprenorphine Initiation for Fentanyl Users

[Paracelsus]

A recent study published in JAMA Network Open has revealed significant challenges in initiating buprenorphine treatment for opioid use disorder (OUD) among people using fentanyl. Conducted in San Francisco, the study evaluated two different low-dose initiation (LDI) protocols—four-day and seven-day regimens—and found that successful initiation and retention rates were alarmingly low. The findings underscore the urgent need for improved strategies to facilitate buprenorphine uptake and retention in the era of fentanyl-dominant opioid use.

The Challenge of Buprenorphine Initiation​

Buprenorphine is a key medication for treating OUD, offering a safer alternative to full opioid agonists like heroin or fentanyl. However, its use has become increasingly complicated due to fentanyl's high potency and long-lasting effects in the body. The main obstacle is the risk of precipitated withdrawal, a severe and sudden onset of withdrawal symptoms that can occur when buprenorphine displaces fentanyl from opioid receptors. To address this issue, clinicians have explored LDI strategies, which involve gradually introducing buprenorphine at very low doses to minimize withdrawal risks.

Despite the promise of this approach, the new study suggests that LDI protocols may not be as effective in real-world outpatient settings. Researchers analyzed 175 buprenorphine initiation attempts among 126 individuals with OUD who reported daily fentanyl use. The participants were treated at two substance use disorder clinics in San Francisco between May 2021 and November 2022.

Study Findings: Low Success Rates and Retention​

The study found that only 34% of LDI attempts resulted in successful buprenorphine initiation, meaning the individual completed the protocol and picked up a refill prescription. Furthermore, retention rates at 28 days were also low, with just 21% of those using the four-day protocol and 18% of those on the seven-day protocol still taking buprenorphine after four weeks.

The researchers found no significant difference in success rates between the two protocols, suggesting that neither the shorter nor the longer regimen offered a clear advantage. However, repeated attempts at LDI were associated with lower success rates, contradicting the expectation that individuals might have better outcomes with multiple initiation attempts.

One key factor influencing success was housing status. Participants who were unstably housed or living in transitional housing had lower odds of successful initiation compared to those with stable housing. This finding highlights the additional barriers faced by people experiencing homelessness, such as medication theft, difficulty managing a complex dosing schedule, and limited access to supportive care environments.

Implications and Future Directions​

The study's findings are concerning, as they indicate that current outpatient LDI strategies may not be effective enough to support widespread buprenorphine adoption among fentanyl users. Given the rising number of fentanyl-related overdoses, researchers argue that more innovative solutions are needed to improve treatment accessibility and retention.

One potential strategy is the use of higher doses of buprenorphine, which may be necessary to counteract fentanyl’s strong effects. Additionally, some experts suggest that injectable formulations of buprenorphine, which provide a slow-release version of the medication, could help overcome the difficulties associated with daily dosing.

Another possible intervention is expanding access to a regulated supply of opioids, such as methadone or hydromorphone, to help patients transition off fentanyl more smoothly. While such an approach is not currently permitted under U.S. law, some harm-reduction advocates argue that safe supply programs could play a critical role in preventing overdoses and improving treatment retention.

The study’s authors emphasize the need for further research to identify more effective initiation strategies. They call for larger clinical trials comparing different buprenorphine initiation methods, as well as qualitative studies to better understand patient and clinician experiences with LDI.

The full study can be accessed at JAMA Network Open:

https://jamanetwork.com/article.aspx?doi=10.1001/jamanetworkopen.2024.56253

If you're interested in such publications, please react and leave comments

 

[Blazey]

I think it's shockingly bad, methadone worked well when I tried it because I could feel it, with bupe I couldn't feel anything, I even IV'd from 1mg to 8mg and the effects were the same, in order for people to stay clean they need a replacement anxiety medicine that works aswel as their DOC

 

[Paracelsus]

A lot of people struggle with buprenorphine (Suboxone/Subutex) for that exact reason—it doesn’t provide the same full agonist "feel" that methadone does. It has a ceiling effect, meaning after a certain dose (around 8–16 mg), you don’t really get stronger effects. Plus, if you were using full agonist opioids before starting, bupe can feel like a brick wall with no warmth or euphoria, which makes it mentally hard to stick with.

Methadone, on the other hand, being a full agonist, provides a steadier, more familiar effect—some even describe it as a safety net for anxiety. It’s not just about opioid withdrawal relief; it also has that long-lasting, calming effect that keeps people functional.

 

[southcloud]

us has to follow suit with Canada. methadone and in addition morphine and hydrophone is the only answer to cdc samsa and fda fucking catastrophe with implementing bunk-ass guidelines which scared the panties off docs. access to opioids is the answer here folks the cat is out of the bag. what do expect millions of Americans who were literally coached into scripts and then pull the fucking rug out underneath them, this is the result!! the only thing we can do and should do is provide access to clean lab grade opioids that are not antagonists along with agonists\. suboxone sucks, i thought it saved my life and then 10 years later my teeth are gone and i brush them i still have my front teeth but chompers are gone and i started to get vertigo out of the blue. also it was harder to come off than heroin methadone any other opioid. the thing is you dont get sick until about a week has past and then you are in the shitter for literally a month. then depressed for about 6 months. its better than nothing i guess but if methadone was not such a fiucking hassle for most peple which cdc has changed guideline any clinic in us can give you 28 takehomes as soon as you start. theres a issue with getting your dose right but when it they can do that . however we dont have the pharmacy infastructure to facilate primary doctors yet but ill bet future good health thats what we will see. unfortunately i doubt high mg hydromorphone will come in addtion or morphine. its the only solution there are a good number probably close to a million who actually could use a script oxycontin because they are in pain which those restrictions have also loosened, doctors are still scared and people are too. and its not fetty fault its mexico putting them in blue roxy form pills. so sick of hearing this scare tactic thats spread to our own community that fetty is the issue, no its doctor and pharm companies rich white men not fucking drugs. i take 240 mg of methadone now and im fight the fight for all of us to be to get take homes so we dont look like they want us to look like standing outside the clinic looking stupid but suffering . those are the lucky one 100,000 of thousands cant get to the clinic. again this isnt a fentanyl issue. blame the people whop are respomnsible drugs to what there supposed to

 

[Paracelsus]

The CDC and FDA guidelines, though well-intentioned to curb opioid misuse and overdose deaths, have had a damaging impact. As you pointed out, doctors got scared. The sharp reduction in prescribed opioids, along with a move toward non-opioid pain management strategies, left many people stranded, particularly those with chronic pain who had been managing their lives with prescribed opioids for years. The result has been a lot of people either turning to illicit sources (where fentanyl is often the main player) or finding themselves in opioid withdrawal with no real support system.

The restrictive guidelines also turned doctors into gatekeepers who, in many cases, were too afraid to prescribe opioids for pain, even when it was appropriate. We know the pendulum swung too far in one direction—away from responsible prescribing—and has created a crisis of its own.

Your experience with Suboxone also highlights a critical point: it's not a "magic bullet" for everyone. While it works for many in the short term, the long-term consequences are often overlooked. The withdrawal symptoms you describe are real for many people, and the physical and psychological toll of tapering off can be far worse than people expect. Suboxone, as an opioid agonist-antagonist, has its own complexities in how it interacts with the body, which can make it a rough road for some people.

And it's not just Suboxone—any long-term opioid use (including methadone) can have significant health consequences, and some individuals may feel more comfortable transitioning to a different form of opioid agonist or even opioid maintenance therapy (OMT) that better fits their needs. It’s key that we don’t treat addiction or pain as one-size-fits-all, and that the treatment is personalized.

Fentanyl, as you mentioned, is often blamed for the overdose crisis, but the root cause is much more complex. The illicit fentanyl epidemic is, in many ways, a symptom of the larger issue—doctors overprescribing in the first place, pharmaceutical companies profiting from widespread addiction, and policies that were slow to address the needs of those who were already dependent. The issue isn’t simply the drug—it’s the system of production, prescription, and distribution that has been broken for decades.

It’s about balance: How can we prevent misuse without criminalizing people who have legitimate pain? How can we ensure that those who need opioid medications have safe access, without exacerbating the addiction crisis? This conversation needs to include compassion, and it needs to include a better understanding of addiction as a medical condition, not a moral failure.

 

[southcloud]

not to mention the suicides. youve put my poorly written rant into the exact words i felt. i read journals everyday hoping for more research into these matters especially long tern use with bup, we pretty much kno the long term effects of methadone the biggest issue is for it to be provided in a doctors office and for fiture options to follow suit otherwise its seen as a nuisance purely because lines are out the door at many clinics. its crazy i would say half of these patients are people who legit need pain medication. there ae a ridiculous number of terminal ill patients standing in line. its a real ugly truth which the victims bare the cross. not to mention the suicides. it seems to me a good enough reason for revolution. are las are no longer protecting the most vunerable

 

[mycelium]

I can't remember what I was looking up a couple of days ago, but my state website states that access to short prescriptions of opioids can help the opiate war, by not making people in pain go get cheap ass fent on the streets .