Medication Assisted Therapy - CME Paid Option-Medication Assisted Therapy

Video Transcription

Video Summary

Dr. Joshua Bloom presents a Compass Opioid Stewardship Grand Rounds on using buprenorphine for opioid use disorder (OUD) and chronic pain, emphasizing challenges posed by illicit fentanyl. Using a case of “Jeff,” a chronic pain patient buying counterfeit “oxycodone” pills that are actually fentanyl, he highlights the ubiquity and lethality of counterfeit tablets and argues against simply “cutting patients off.” Instead, clinicians should use motivational interviewing, provide naloxone, and connect patients to OUD treatment.<br /><br />He explains why standard buprenorphine induction often fails with fentanyl: repeated fentanyl use behaves like a long-acting opioid due to high lipophilicity and tissue redistribution, increasing risk of precipitated withdrawal when buprenorphine displaces full agonists from receptors. Management options include supportive meds, completing induction with higher-dose “macrodosing” in monitored settings, or aborting induction outpatient.<br /><br />To prevent precipitated withdrawal, he describes buprenorphine microdosing (e.g., Bernese method), starting very low doses while patients continue their baseline opioid, then stopping the opioid once therapeutic buprenorphine is reached. He also discusses buprenorphine for pain: split dosing (3–4x/day) may improve analgesia, and transdermal buprenorphine can be first-line even in opioid-naïve patients due to improved safety and lower respiratory depression risk. He reviews common insurance/prior authorization considerations and concludes there is no one-size-fits-all approach.

Keywords

buprenorphine

opioid use disorder (OUD)

illicit fentanyl

precipitated withdrawal

buprenorphine induction

microdosing (Bernese method)

macrodosing

chronic pain management