For years, buprenorphine has been hailed by doctors and patients alike as a life-saving medication, the most critical component of treatment for opioid use disorder (OUD).
“Amazing,” “a godsend,” “armor against cravings” — that’s how patients in recovery, even those with a long history of IV heroin use, describe the medication, commonly known as Suboxone.
However, Suboxone treatment has presented challenges among those addicted to fentanyl.
It’s not that Suboxone doesn’t work well for fentanyl addiction. It does — very well, in fact.
When taken at the right time, Suboxone suppresses the nausea, muscle aches, and anxiety that make full-blown withdrawal miserable. The medication also quells the intense cravings that drive opioid addiction.
But to avoid becoming violently ill, with a condition known as “precipitated withdrawal,” patients using long-acting opioids like fentanyl must abstain for 36 hours before their first Suboxone dose.
That’s 12 hours longer than the abstinence period required for heroin or prescription-painkiller addiction — and far longer than most fentanyl patients can endure. Fentanyl is up to 50 times more potent than heroin and 100 times more potent than morphine, making the high from this synthetic opioid more intense and the withdrawal more extreme.
“A lot of folks feel so incredibly sick after 6 to 8 hours they give up,” says Dan Goulette, an Ideal Option provider.
The good news: Thanks to a new treatment protocol, fentanyl-dependent patients now have a more bearable path to recovery with buprenorphine. The protocol, offered by Ideal Option, involves “micro-initiation” of Suboxone.
Patients start with a tiny dose of Suboxone and gradually increase the dose while gradually decreasing fentanyl intake. After about 5 days, patients are able to stop using fentanyl and maintain a conventional starting dose of Suboxone, an important first step on the path to recovery.
The difference: They’ve bypassed 36 hours of suffering.
“This approach has been much more comfortable and successful for our patients,” says Dan. “I’ve had so many fentanyl-dependent patients tell me, ‘There’s no way I could have done this any other way.’”
Micro-initiation, also known as micro-dosing, may be unconventional, but the rise of fentanyl — a synthetic opioid 50 times more potent than heroin — has made this approach critical.
“It’s a necessity to address the soaring rates of fatal fentanyl overdose,” says Ben Rae, an Ideal Option provider.
In 2020, an estimated 93,000 Americans died of a drug overdose, 29% increase over 2019, according to the National Center for Health Statistics. Some 75% of those deaths involved opioids, primarily fentanyl.
Fentanyl has flooded the illegal drug supply, supplanting heroin almost entirely.
“Because fentanyl is so cheap to produce, it’s being cut into all sorts of drugs of abuse – ecstasy, marijuana, cocaine, meth,” says Dan.
At Ideal Option, there was a 93% increase in patients testing positive for fentanyl at enrollment in May ‘21 compared to May ‘20. Even more alarming, patients are younger than ever.
Ben has teenage patients who are so severely addicted to fentanyl that they can’t sleep through the night without using and can’t keep up in school or sports or keep a job.
“It’s as if you’re talking to a two-year IV heroin user, but they’ve only been using fentanyl for three months. Their lives were ripped from them really quickly.”
Dan, too, has treated high-school students. “They’re sick all the time and feel like they’ve lost control,” he says. “Their brain’s entire focus is: How do I get my next fentanyl pill?
With micro-initiation, patients now have a reasonable chance of reclaiming their lives.
Why Micro-Dosing Suboxone Works for Fentanyl Addiction
The micro-dosing approach reflects an improved understanding of how the body processes fentanyl.
“Fentanyl builds up in the fatty tissue, and it takes a much longer time to clear out of the body than heroin or oxycodone,” Dan explains. “We used to think that fentanyl-dependent patients could just wait 24 hours, like with other opioids, but that just doesn’t work.”
For these patients, the consequences of taking a conventional dose of Suboxone too soon — before fentanyl has vacated the brain’s opioid receptors — can be disastrous.
The medication hurls them into precipitated withdrawal, an intense form of withdrawal “precipitated” by the initiation of buprenorphine rather than by the natural course of abstaining.
What happens is this: Buprenorphine very quickly dislodges fentanyl off the brain’s opioid receptors. But because buprenorphine is exponentially less potent than fentanyl, “this creates a net deficit, which the body experiences as severe withdrawal,” Dan explains.
This scenario is far worse than what happens when heroin-dependent patients start treatment. For these patients, abstaining for 24 hours is typically uncomfortable — even downright miserable for some — but the nausea and aches come on gradually and never reach extreme levels.
Dan says that observing patients in precipitated withdrawal is not something you forget.
“They’re sheet pale, vomiting, unable to control the movement of their arms and legs. They have headaches, muscle cramping, and diarrhea. It reaches maximum intensity right away and can last a full 48 hours.”
No wonder most patients give up and never want to try again.
“You can develop an aversion to Suboxone, where you’ll avoid it at all costs,” says Ben. “We really want to avoid that situation, where someone is totally repelled from the medication.”
Micro-dosing of Suboxone allows patients to bypass the entire agonizing scenario.
The medication is introduced gradually so it doesn’t abruptly displace the fentanyl on the brain’s opioid receptors.
“In the course of a 4- to 5-day period, the patient’s anxiety level is dramatically decreased because they’re not worrying about precipitated withdrawal or cravings,” says Dan.
Throughout the process, patients visit with their Ideal Option provider every couple of days and a registered nurse checks in via text or phone daily. Some patients may also take medications to reduce any restlessness, anxiety, or nausea they may be feeling.
“The process is a bit more complicated than conventional initiation, so it’s best to have supervision of an addiction specialist,” says Dan.
Ideal Option providers are thrilled they can offer micro-dosing, especially to patients who have experienced precipitated withdrawal and will not go down that road again.
Says Ben: “Patients tell me, ‘I’ve always wanted Suboxone to work for me, but I could never get that far. But this time it worked. I feel normal again, and I’ve gotten my life back.”