An increasing number of PAs and nurse practitioners (NPs) are working in addiction medicine including opioid treatment programs (OTPs) where they are increasingly able to practice autonomously. A recently released commentary in the Journal of Substance Abuse Treatment highlights the challenges that practitioners at OTPs face in reaching therapeutic doses of methadone for patients who are using fentanyl instead of heroin.1 The commentary authors noted that with “fentanyl’s increased potency when compared to other opioids, many papers have described the need for higher doses of methadone to achieve the therapeutic goal of reducing and suppressing opioid withdrawal and subsequent illicit ongoing fentanyl use.”
The commentary authors make several key observations and related recommendations. One key finding is that patients using fentanyl who enter OTPs may view the increased time needed to achieve an effective dose of methadone as evidence that methadone treatment will not work for them, and that this may serve as yet another barrier to treatment.
Current guidelines for methadone treatment by the Substance Abuse and Mental Health Services Administration (SAMHSA) recommend a maximum initial dose of 30 mg per federal OTP regulations, which were established before synthetic opioids became the leading cause of opioid-involved deaths in the United States. Guidelines state that the dose may be increased by 5 mg to 10 mg every 3 to 5 days. This dosing schedule may be ineffective for patients using fentanyl given their higher tolerance; it may take up to a month or more to reach an effective methadone dose in these patients.
The commentary authors offer several points to consider when adapting induction protocols to meet the therapeutic needs of patients using fentanyl and noted that change can be achieved without lengthy regulatory reform. The authors offer evidence from several US studies in which a more rapid methadone induction schedule allowed achievement of therapeutic doses more quickly without an increase in the risk for overdose, which is highest risk during the first few weeks of methadone induction in OTP settings.
This evidence indicates that OTP providers are attempting to address these concerns with a variety of induction variations, suggesting that more research focused on patients using fentanyl is needed.
This commentary is valuable in attempting to spur further innovative efforts to adapt the methadone OTP model to meet the challenges presented by the greater potency of fentanyl. Engagement early in induction can be challenging for any patient with opioid use disorder seeking treatment. Even before the rise in fentanyl use, many patients with opioid use disorder struggled with the induction period when they were initiated on doses that do little early on to suppress withdrawal symptoms, which are common. This problem is even greater now with the rise in fentanyl use, and this commentary demonstrates the need for OTPs to offer a model for how OTPs and OTP regulators can design more effective induction protocols that are both safe and effective.
Buresh M, Nahvi S, Steiger S, Weinstein ZM. Adapting methadone inductions to the fentanyl era. J Subst Abuse Treat. 2022;141:108832. doi:10.1016/j.jsat.2022.108832