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Video Summary

Dr. Joshua Bloom presents Compass Opioid Stewardship Grand Rounds on using buprenorphine for opioid use disorder (OUD) and chronic pain in the era of widespread illicit fentanyl. A case of “Jeff,” using counterfeit “oxycodone” pills that are actually fentanyl, illustrates how difficult it is to identify fake tablets and how common lethal fentanyl doses are. Bloom emphasizes that cutting patients off opioids is not evidence-based for OUD and can worsen risk; better approaches include motivational interviewing, offering naloxone, and facilitating treatment.<br /><br />He explains why fentanyl complicates standard buprenorphine inductions: repeated fentanyl use behaves like a long-acting opioid due to lipophilicity and tissue redistribution, increasing risk of precipitated withdrawal when buprenorphine (high receptor affinity, partial agonist) displaces full agonists. Management options for precipitated withdrawal include supportive meds, ED/inpatient “macrodosing,” or aborting outpatient inductions; prevention often relies on microdosing (“Bernese method”), slowly titrating tiny buprenorphine doses while continuing the full agonist, then stopping it once therapeutic levels are reached.<br /><br />For chronic pain, buprenorphine can be transitioned via microinduction and may need split dosing for analgesia. Buprenorphine patches can be used even in opioid-naïve patients and may be safer (lower respiratory depression risk, potential benefit on hyperalgesia/mood). He briefly reviews variable state Medicaid prior-authorization requirements and concludes there is no one-size-fits-all strategy.

Keywords

buprenorphine

opioid use disorder (OUD)

illicit fentanyl

precipitated withdrawal

microdosing (Bernese method)

buprenorphine induction

chronic pain management

naloxone