Medications for Opioid Use Disorder Remain Effective as Highly Potent Synthetic Opioids Permeate North American Illicit Drug Supplies

Over the last ten years, highly potent synthetic opioids (HPSO) like fentanyl and fentanyl analogues have overtaken the illicit opioid drug supply in North America. This scoping review summarized the evidence regarding medications for opioid use disorder (MOUD) treatment outcomes for individuals exposed to HPSO, and explores directions for future research.

• Thirty-four observational studies met inclusion criteria.
• Most studies described the feasibility of low-dose buprenorphine initiation with opioid continuation protocols. A few studies described high-dose buprenorphine initiation protocols with extended release buprenorphine.
• Higher daily buprenorphine dose (>16mg per day) was observed to be more effective than lower doses in a few studies.
• Both buprenorphine and methadone were found to be effective to prevent death and opioid overdose in two observational studies.
• One observational study found that initiation of extended-release naltrexone was less likely in individuals exposed to HPSO than in those who were not.

Comments: This scoping review reinforces findings from similar studies that identified a high prevalence of HPSO in the illicit opioid drug supply, and found that MOUD remains highly effective for preventing opioid overdose and premature death among people exposed to HPSO. MOUD initiation processes and uncertainty about the most effective dose to improve treatment outcomes remain open areas for rigorous research, although observational studies suggest that low-dose buprenorphine initiation techniques and higher MOUD dosing strategies are effective. The bottom line is that MOUD remains highly effective to prevent overdose and death, when it is prescribed.

Melissa B. Weimer, DO, MCR

Reference: Jegede O, De Aquino JP, Hsaio C, et al. The impact of high-potency synthetic opioids on pharmacotherapies for opioid use disorder: a scoping review. J Addict Med. 2024;18(5):499–510.