A lot of people have been working on the fentanyl problem for a few years now. There are different strategies that can be taken and different ones work for different people. Here are some of the options that are used most often.
Option 1: Go Inpatient
Inpatient detoxification programs have the ability to do EXTREMELY low dose inductions (sometimes referred to as microdosing). They can use patches or IV versions of the buprenorphine so that you are getting only a fraction of a milligram of buprenorphine to start. You can then increase the amount by a couple tenths of a milligram as well. These amounts are so low that it does not trigger the withdrawal. It will take about 5-14 days, though, to get the buprenorphine to full strength.
It may be difficult in some areas to find inpatient settings that do this type of induction or that take your insurance. Even if your detox does not do this type of medication, if you can last a few days in the more supported environment of an inpatient detox so that most of the medication is out of your system when you leave, you can then start the full dose of your buprenorphine medication once you leave- the fentanyl is then mostly out of your system.
Option 2: Methadone
Methadone does not have the same problems that buprenorphine does- it will not make you sick when you take it. It is then very easy to get on methadone from fentanyl. Methadone can start at about 30-40 milligrams a day and increase you by 5-10 mg every couple of days. People may need >100mg to feel completely ok. The methadone clinics are trying to increase people’s methadone doses more quickly than they did in the past but still are limited by safety and some federal restrictions.
Many methadone clinics now offer buprenorphine as well as methadone. It can be tricky to get form methadone to buprenorphine similar to how it is tricky with fentanyl but there are techniques and ways. Some people may start on methadone to help them stabilize and then transition to buprenorphine with the help of their clinic later.
Option 3: High Dose Induction: Pedal to the Metal
This method is now well studied in the emergency room (ER) setting1. Persons would come into the ER in severe withdrawal. ER doctors start by giving 16-24 mg of buprenorphine all at once, right off of the bat. The rationale here is that the person feels very bad and we are already behind treating their withdrawal. So we are going to push the last of the fentanyl out of their system as quickly as possible and replace it all with buprenorphine all at once- none of this slow trickling in and out. People may get 32-64 mg of buprenorphine on the first day. Studies show this is very effective and in one major study <1% of people had any precipitated withdrawal with this approach.
This technique can still be challenging to do in a regular outpatient clinic setting. It is hard for someone to wait long enough to go into severe withdrawal. Anxiety in particular tends to cause people to jump the gun. Supportive medications to help relieve anxiety, cramping, diarrhea, and restlessness are prescribed with the buprenorphine to help the person wait as long as possible before taking their first dose- ideally at least 24 hours. It is also helpful to have friends and loved ones support you during this time in a calm environment.
Option 4: A Variation on the Old Way
Some providers have still found some strategies similar to how we used to do it that can work. You would wait until you have had about 6 hours from last dose and a few physical signs of withdrawal. Then you build up the medication over time. You would use 0.5 mg (a 2 mg suboxone film cut into 4 pieces) at first and then increase to 1mg at time then 2 mg at a time and finally 8 mg at a time. You would be at 16-24 mg by the end of the day. In this method you are going lower and slower than we would have in the past but not quite as slow as some of the inpatient detox clinics can go. It helps to have people support you, keep you occupied, and help you keep track of the medicine. You would be given medicines to help keep you more comfortable.
Option 5: The Long-Acting Shot
It is injected into the body and then slowly releases into the blood stream. It will not reach its full strength in your blood stream until 24 hours after the shot- it is slowly releasing in. There are also week long versions of the medication. The theory is that this slowly leaks into your blood stream from the injection site. This slow leak into the blood stream is similar to the very slow, low dose inductions done in an inpatient detox. The other benefit is that once the shot is given you can’t take it back- even if you use, the shot is going to continue to release the medication and slowly take its place. This means you don’t have to ‘start over’ and try again to get on the medication.
In the largest study so far of this technique with Sublocade, people were brought into the ER after an overdose reversal and were then given the shot after tolerating 4 mg of buprenorphine. In the clinic, people are experimenting with having people prove they can tolerate much lower doses to show they are not allergic and the timing for how long to wait from last use before the shot is still being worked out.
Footnotes
AA H, AA V, J L, et al. High-Dose Buprenorphine Induction in the Emergency Department for Treatment of Opioid Use Disorder. JAMA network open. 07/01/2021 2021;4(7)doi:10.1001/jamanetworkopen.2021.17128↩︎
TA O, KJ R, TT D, et al. Rapid induction onto extended-release injectable buprenorphine following opioid overdose: A case series. Drug and alcohol dependence reports. 03/16/2023 2023;7doi:10.1016/j.dadr.2023.100144↩︎
KW L, A M, I G, B H, M D, JM K. Initiation and Dosing of Extended-Release Buprenorphine: A Narrative Review of Emerging Approaches for Patients Who Use Fentanyl. Substance abuse and rehabilitation. 03/25/2025 2025;16doi:10.2147/SAR.S516138↩︎
Reuse
Citation
@online{barnes2025,
author = {Barnes, Erin},
title = {Why {Is} {Getting} on {Buprenorphine} {So} {HARD} {These}
{Days?!} : {Part} 2},
date = {2025-11-21},
url = {https://wakeforestid.com/posts/2025-11-20-why-is-getting-bup-so-hard-2/},
langid = {en}
}