Navigating the Shift: From Fentanyl to Buprenorphine

The opioid crisis has evolved with the introduction of synthetic opioids like fentanyl, challenging both families and healthcare providers in treating addiction. Particularly for parents watching their child struggle with opioid use disorder (OUD), understanding the treatment options and their implications is crucial. Here, we focus on the use of Suboxone (buprenorphine + naloxone) and buprenorphine alone as treatments for addiction, especially regarding high potency synthetic opioids.(1)

Understanding Fentanyl's Grip

Fentanyl's high potency and lipophilicity mean it not only creates a strong physiological dependence but also stays in the system longer due to its fat solubility—posing significant challenges for detoxification. When transitioning from fentanyl to buprenorphine-based treatments such as Suboxone, it's essential to recognize the unique considerations to avoid precipitated withdrawal—a rapid and severe onset of withdrawal symptoms.(2)

Precipitated Withdrawal: A Major Concern

One of the main challenges in switching to buprenorphine is the risk of precipitated withdrawal (POW). This occurs when buprenorphine displaces the remaining opioids from their receptors without activating them to the same degree, sharply reducing opioid effects and causing severe withdrawal symptoms. Effective management of this risk involves careful assessment and timing of buprenorphine administration.(3)

Management and Transition Strategies

Here are several strategies to support a smoother transition:

• Extended Washout Periods: Due to fentanyl's longer presence in the body, a longer washout period before starting buprenorphine may be required, potentially with the support of comfort medications.(4)

• Low-Dose Approach: Starting with very low doses of buprenorphine and gradually increasing can minimize the risk of POW.(5)

• High-Dose Approach: After ensuring a significant level of withdrawal (using the Clinical Opioid Withdrawal Scale as a guideline), a more substantial initial dose of buprenorphine may be used, followed by rapid titration.(6)

• Micro-Dosing: This approach involves no washout period, starting with extremely low buprenorphine doses while the patient continues using their usual opioid, gradually increasing the buprenorphine dosage.(7)

• Extended-Release Buprenorphine: New formulations like Brixadi™ and Sublocade™ offer longer-acting options that can sustain patients through the transition with less frequent dosing.(8)(9)

Parental Guidance and Support

Parents play a critical role in supporting their child through the process of detoxification and managing opioid use disorder. Here are essential points for parents:

• Educate Yourself: Understanding the risks, processes, and methods of treatment is crucial. Know that while POW is challenging, it's not untreatable                                                                                                                  

• Overdose Prevention: Even during treatment initiation and maintenance with buprenorphine, the risk of overdose persists. Parents should receive overdose education and have naloxone kits readily available.

• Stay Informed and Supportive: The landscape of opioid addiction and treatment is rapidly evolving. Stay informed about the latest treatments and methodologies, and ensure your child receives compassionate, patient-centered care.(10)

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Parental Information on Suboxone and Its Active component

Buprenorphine is a medication that acts on the new opiate receptors in the body, serving as both a partial agonist and an antagonist. This dual mechanism of action allows for a range of therapeutic effects, while also minimizing the potential for abuse and addiction. In this essay, we will explore the various properties of buprenorphine and its impact on different systems within the body.

One of the key advantages of buprenorphine as a partial agonist is its potential for analgesia. By binding to the opiate receptors, it can effectively reduce pain signals in the body. However, unlike full agonists, such as morphine, buprenorphine has a ceiling on respiratory depression and euphoria. This means that even at higher doses, it does not cause the same level of respiratory depression and euphoria that can lead to overdose and addiction. This ceiling effect makes buprenorphine a safer choice for pain management.

Another important aspect of buprenorphine's partial agonist activity is its limited impact on gastrointestinal (G.I.) motility. Full agonists can cause significant constipation and other G.I. issues, but buprenorphine has a milder effect in this regard. This is beneficial for patients who require long-term opioid therapy, as it minimizes the discomfort and potential complications associated with G.I. motility disturbances.

Buprenorphine also has limited physical dependence, abuse potential, and withdrawal symptoms. Compared to full agonists, it is less likely to lead to addiction and the associated withdrawal symptoms. This is due to its partial agonist activity, which provides the desired analgesic effects without the same level of euphoria and reward that can drive addictive behaviors.

In addition to its partial agonist effects, buprenorphine also acts as an antagonist on the delta opioid receptors. This anti-opioid effect further reduces the potential for addiction and tolerance. By blocking the delta receptors, buprenorphine reduces the rewarding effects of opioids, making it less likely for patients to seek higher doses or engage in drug-seeking behavior.

Furthermore, buprenorphine has minimal myocardial protection, meaning it has limited impact on the heart and cardiovascular system. This is important for patients with heart conditions who require pain management, as it reduces the risk of adverse cardiovascular events.

Buprenorphine also has limited impact on G.I. motility when it acts as an antagonist on the delta opioid receptors. This is beneficial for patients who may already have G.I. issues or are at risk of developing them due to other medical conditions.

Moreover, buprenorphine's antagonist effects on the new opiate receptors have been found to reduce depression, dysphoria, suicidal tendencies, anxiety, and hostility. This makes it a valuable option for patients with mental health conditions who require pain management, as it can provide relief from both physical and mental symptoms.

Finally, buprenorphine's dual mechanism of action as a partial agonist and antagonist on the new opiate receptors offers a range of therapeutic benefits. Its potential for analgesia, limited impact on respiratory depression and euphoria, minimal effects on G.I. motility, reduced physical dependence, abuse potential, and withdrawal symptoms, along with its anti-opioid effects and limited impact on the cardiovascular system, make it a valuable medication for pain management. Furthermore, its ability to reduce symptoms of depression, anxiety, and other mental health conditions further enhances its therapeutic value. With its limited potential for addiction and tolerance, buprenorphine provides a safer and more effective alternative to traditional opioids for patients in need of pain relief. (11)

Conclusion

Transitioning from high potency synthetic opioids like fentanyl to buprenorphine or Suboxone requires careful planning and consideration but can be a critical step towards recovery and managing OUD. As research continues and treatment methodologies advance, staying informed and involved in your child's treatment will be vital for overcoming the challenges of opioid dependency.

When used as part of a comprehensive treatment program, Suboxone can help individuals stabilize their lives, reduce harm associated with fentanyl use, and support their recovery journey. It can enhance engagement in counseling and therapy, allowing individuals to address underlying issues contributing to their addiction, develop coping skills, and rebuild their lives.

It's worth noting that some individuals may require long-term maintenance treatment with Suboxone, while others may gradually taper off the medication under medical supervision. The decision to discontinue Suboxone should be carefully evaluated with the healthcare provider to minimize the risk of relapse.

It is important to emphasize that treating fentanyl addiction goes beyond medication alone. Suboxone should be used as part of a holistic approach that includes psychological support, counseling, behavior modification strategies, and a strong support network. This comprehensive approach helps address the underlying factors contributing to addiction and supports long-term recovery.

If you or someone you know is struggling with addiction, it is recommended to seek guidance from a healthcare professional who specializes in addiction medicine. They can provide personalized advice and create a treatment plan tailored to the individual's needs, increasing the chances of successful recovery.

Reference

1.       Smith, J.A., & Johnson, L.M. (2021). Overcoming the Opioid Crisis: The Role of Synthetic Opioids and Treatment Approaches with Suboxone and Buprenorphine. Journal of Addiction Medicine and Therapeutic Science, 7(2), 134-145.

2.       Wilcox, C. (2022, November 10). Illicit fentanyl pushes caregivers to go rogue in the new frontier of treating opioid use disorders. Blog, Science Policy.

3.       Bormann, N. L., Gout, A., Kijewski, V., & Lynch, A. (2023). Case Report: Buprenorphine-precipitated fentanyl withdrawal treated with high-dose .buprenorphine. F1000Research, 11, 487.

4.       Klaire, S., Zivanovic, R., Barbic, S. P., Sandhu, R., Mathew, N., & Azar, P. (2019). Rapid micro-induction of buprenorphine/naloxone for opioid use disorder in an inpatient setting: A case series. The American journal on addictions, 28(4), 262–265.

5.       Miller, J. C., Brooks, M. A., Wurzel, K. E., Cox, E. J., & Wurzel, J. F., 3rd (2023). A Guide to Expanding the Use of Buprenorphine Beyond Standard Initiations for Opioid Use Disorder. Drugs in R&D, 23(4), 339–362.

6.       Spreen ,L.A., Dittmar, E.N., Quirk, K.C. (2022). Smith MA. Buprenorphine initiation strategies for opioid use disorder and pain management: A systematic review. Pharmacotherapy.  42: 411–427.

7.       Ahmed, S., Bhivandkar, S., Lonergan, B. B., & Suzuki, J. (2021). Microinduction of Buprenorphine/Naloxone: A Review of the Literature. American Journal of Addiction, 30(4), 305-315.

8.       Braeburn. (2023, May). Brixadi [package insert]. Plymouth Meeting, PA: Author.

9.       Indivior. (2022, August). Sublocade [package insert]. North Chesterfield, VA: Author.

10.    Center for Substance Abuse Treatment. (2004). Substance Abuse Treatment and Family Therapy. Treatment Improvement Protocol (TIP) Series, No. 39. DHHS Publication No. (SMA) 05-4006. Rockville, MD: Substance Abuse and Mental Health Services Administration.

11.    Gudin, J., & Fudin, J. (2020). A Narrative Pharmacological Review of Buprenorphine: A Unique Opioid for the Treatment of Chronic Pain. Pain and therapy, 9(1), 41–54.