Treating Fentanyl Withdrawal
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Through the year 2019, the opioid epidemic has been described as the most significant public health crisis of this century. In 2017, approximately 50,000 Americans died because of opioid overdoses, more than all Americans who perished in the Vietnam War. The rising number of deaths from opioids is attributable to many factors including most recently a rise in illicitly manufactured fentanyl.1 Fentanyl has unique pharmacological properties including high potency which render it particularly lethal. Less has been written around its pharmacological profile’s contribution to withdrawal symptoms.2 Like other opioids, fentanyl cessation generates a withdrawal; however, some have posited that fentanyl withdrawal may be more uncomfortable and difficult leading to increased challenges around engagement and retention for those experiencing it and prescribed Suboxone or methadone as part of a comprehensive opioid use disorder treatment regimen.3 Such a potentially amplified fentanyl-associated withdrawal syndrome is of import in parts of the country where fentanyl has become omnipresent in the heroin supply.4 Our anecdotal experience within Philadelphia’s public behavioral health system which includes ambulatory opioid treatment programs and residential drug and alcohol treatment facilities suggests that treatment of opioid use disorder in a population with high fentanyl penetrance may require a higher dose of medication-assisted treatment agents both at initiation of and through maintenance treatment. For instance, it is not uncommon that 24 mg of buprenorphine is necessary to manage withdrawal symptoms during an induction or to hear reports that standard methadone dosages at a clinic have increased by 10%. Such observations need be contextualized within the field’s longstanding cognizance that higher dosages of opioid agonists enhance certain outcomes including retention in treatment. 5 Given the widespread prevalence and in some locations ubiquity of fentanyl in the heroin supply, such observations suggest that additional quantifiable research on optimal induction and Address correspondence to Geoff Neimark, MD, University of Pennsylvania, Philadelphia, PA, USA. . Chris Tjoa, MD, Community Behavioral Health, Philadelphia, PA, USA. Publisher’s Note Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
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Journal of Behavioral Health Services & Research, 2020. 1–1. c 2020 National Council for Behavioral Health. DOI 10.1007/s11414-020-09710-8
Treating Fentanyl Withdrawal
NEIMARK & TJOA
maintenance dosing in such populations for both buprenorphine and methadone is indicated. Furthermore, facilities and providers involved in the treatment of opioid use disorder where fentanyl penetrance is high should re-evaluate their current standardize dosing protocols and continue to monitor potentially related outcome measures such as against medical advice rates to gauge potential impact. Addition of fentanyl testing to standard drug testing should also be considered as it may i
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