An increasingly common protocol for treating people who use illicit fentanyl has low odds of success, new research suggests. While there are myriad reasons people don't complete treatment, one factor is the fear of withdrawal triggered by medication treatment. How so? Buprenorphine, a drug used to treat people with opioid use disorder, is less restricted than methadone, which is also used to wean people off opioids. But despite efforts to increase buprenorphine usage, uptake is low. One reason so few people opt for buprenorphine is that the medicine can trigger withdrawal symptoms, according to a study published in JAMA Network Open in January. To decrease withdrawal risk, some providers offer low doses of buprenorphine over four or seven days. Inside the study: Researchers from San Francisco General Hospital, the San Francisco Department of Public Health and the University of California followed nearly 130 people who tried the low-dose buprenorphine strategy in San Francisco between May 2021 and November 2022. The results weren’t promising. Of 175 treatment attempts, roughly 1 in 3 were successful. Of the attempts at initiating the four-day regimen of low-dose buprenorphine, 21 percent were still consistently taking buprenorphine a month later. Completion rates for those who followed the seven-day initiation protocol were even lower: 18 percent. The new protocol rates were also lower than in prior studies of people in the pre-fentanyl era who used heroin or prescription opioids, which reported more than 90 percent success rates for initiating buprenorphine treatment, researchers said. Study limitations: In addition to being a small, retrospective study, the research was conducted only at a single center, so outcomes could be different in another setting. The study population also included high numbers of participants who'd previously used buprenorphine and who inhaled fentanyl, which is associated with higher opioid tolerance. Those limitations suggest further research with larger, more diverse populations is needed to better understand how well low-dose buprenorphine initiation works. The bottom line: In addition to the risk of buprenorphine triggering severe withdrawal, people in treatment faced additional barriers, particularly those who were homeless, such as high risk of medication theft and not having a safe place to handle withdrawal symptoms. Given those challenges, it’s not surprising that the new treatment protocol would have less successful initiation rates. Previous research suggests that fentanyl withdrawal may be more severe and enduring and have a quicker onset than heroin withdrawal. The significantly lower success rates for those using illicit fentanyl than for those using heroin or prescription drugs highlight the need for better buprenorphine care and retention, the researchers argue. Health care providers still face challenges getting people with fentanyl addiction into treatment, the study shows. While the total number of overdose deaths has started decreasing over the last year, it remains high among some groups, such as Native Americans.
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