The Rewards of Working in Addiction Psychiatry

The misuse of fentanyl and its analogues has become the pivotal feature of the opioid epidemic. Fentanyl analogues have a longer and less predictable half-life compared with heroin, meaning that, instead of the relatively short drug-free period usually required before beginning treatment after the use of heroin, fentanyl patients experience precipitated withdrawal even after waiting for several days since their last use. Many patients find themselves unable to tolerate this more prolonged “wash-out” period and are thus unable to initiate either buprenorphine or antagonist treatment. Providers have turned their attention to other induction techniques, such as microdosing and macro-dosing, to resolve this problem.

Microdosing induction of buprenorphine, also known as the Bernese method, was first described in 2010 (Hammig, et al., 2016). Not widely used before the rampant misuse of fentanyl and its analogues, the technique of microdosing involves the introduction of treatment medications, beginning with very low doses of buprenorphine to minimize the risk of precipitated withdrawal. Patients are not required to stop taking their full-agonist opioid (e.g., heroin, oxycodone, etc.) and do not experience any opioid withdrawal symptoms, cravings, or the associated relapse risk for opioid use.

The blocking medication is titrated up gradually over two to 10 days, during which the patient may or may not continue taking their full-agonist opioids. Once an effective blocking level is reached, the full-agonist can be stopped completely, and the dose of buprenorphine can then be titrated up rapidly as needed. Patients typically experience no withdrawal symptoms using this method.

Microdosing induction can be used with sublingual tablets/film, transdermal patches, or IV formulations, usually beginning at the smallest possible dose (not all of these formulations are approved for clinical use of OUD in the United States). Research has shown that this technique is safe for patients who are using heroin, fentanyl, or methadone, up to 120 mg daily (Ghosh, et al., 2019).

Macro-dosing is another useful strategy that has been utilized in emergency departments (ED) and inpatient units. The aim is to stabilize the patient on a full therapeutic dose of buprenorphine as rapidly as possible. The patient is observed in the ED or inpatient unit after being given a dose of 4 to 8 mg of sublingual buprenorphine. After ensuring that the patient did not suffer precipitated withdrawal, either the dose of buprenorphine is rapidly increased, often up to 24 mg in the first 24 hours, or extended-release subcutaneous buprenorphine is administered (Snyder, et al., 2023). This technique is being used in urban settings where offering the maximum benefit of treatment at the patient’s initial presentation is critical. It has shown minimal risk for precipitated withdrawal (D’Onofrio, et al., 2023).

Opioid agonist therapy remains the best option currently available for treating patients with OUDs. Long-term buprenorphine treatment, while more accessible than methadone, has an additional challenge compared with methadone due to the need for a wash-out period following the last use of a full-agonist opioid. Fortunately, the use of microdosing and/or macro-dosing induction of buprenorphine has been able to meet the challenge head-on and help patients who need immediate quality treatment for their OUD.

For an addiction psychiatrist, the opportunities for useful research are plentiful. While we have a number of effective medication treatments for patients with OUD, we still face an epidemic of opioid overdoses. If we are to successfully address this epidemic, we must address these implementation challenges—and, if you choose a career in addiction psychiatry, you can help lead the way. ■

Hämmig R, Kemter A, Strasser J, et al.: Use of microdoses for induction of buprenorphine treatment with overlapping full opioid agonist use: the Bernese method. Subst Abuse Rehabil 2016; 7:99–105.

Ghosh SM, Klaire S, Tanguay R, et al.: A review of novel methods to support the transition from methadone and other full agonist opioids to buprenorphine/naloxone sublingual in both community and acute care settings. Can J Addict 2019; 10(4):41-50.

Snyder H, Chau B, Kalmin MM, et al.: High-dose buprenorphine initiation in the emergency department among patients using fentanyl and other opioids. JAMA Netw Open 2023; 6(3):e231572-e231572.

D’Onofrio G, Edelman EJ, Hawk KF, et al.: Implementation facilitation to promote emergency department–initiated buprenorphine for opioid use disorder. JAMA Netw Open 2023; 6(4):e235439-e235439.