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• Fentanyl stays in the brain’s opioid receptors longer than other opioids.
• If a patient is given one of the top fentanyl use disorder medications, they may experience severe withdrawal.
• Withdrawal symptoms can cause patients to relapse, interrupting recovery and putting their lives at risk.

For years, doctors and other medical caregivers have been required to become certified to prescribe a drug to patients with opioid use disorders to treat addiction and reduce overdose deaths.

The drug is U.S. Food and Drug Administration-approved buprenorphine, commonly known by one brand name, Suboxone. Taking it as prescribed is one of the most effective ways to treat patients and protect them from overdose.

Ideally, patients can start buprenorphine without experiencing severe withdrawal. If they used heroin or other opioids, they may need to wait 12 hours to a couple of days after their last use before taking the drug.

But with fentanyl, the wait is much longer. And if buprenorphine is started too soon, it can cause the patient to go into severe withdrawal and return to fentanyl use.

“I call fentanyl sticky”

Fentanyl stays in a person’s body, at mu opioid receptors in the brain, longer than other opioids.

“I call fentanyl sticky because it sticks to the receptors for so long,” said Dr. Mina “Mike” Kalfas, a board-certified addiction expert at the Travel Recovery Center in St. Elizabeth Healthcare in Northern Kentucky. “It’s just the nature of the drug. Each drug has its own unique action on the (mu opioid) receptor, and that’s unique to fentanyl.”

Kalfas began treating patients with Suboxone nearly 20 years ago, when the drug was new. Prescription painkiller abuse was on the rise in Kentucky, and heroin was coming onto the scene. He started with half a dozen Suboxone patients and has grown to about 250 at any given time to whom he prescribes the drug.

Now, most of them come to be treated for fentanyl addiction.

And Kalfas is seeing a new problem: Patients addicted to fentanyl are having to wait longer to start the medication regimen, he said. This means enduring days in retreat. Because if they are given buprenorphine too soon or at too high a dose, they can experience excruciating withdrawal, known medically as precipitated withdrawal.

Symptoms are so bad that people with opioid use disorder can relapse.

“The problem is, once they start retreating, they run,” Kalfas said. “They feel terrible, because withdrawal is what they fear the most.”

Fentanyl presents a unique public health challenge, treatment

It’s a situation that opioid addiction experts have known about for a few years, as fentanyl has overtaken heroin and been found in a number of other drugs of abuse.

Dr. Adam Bisaga, an addiction research specialist at Columbia University, noted in a 2019 report that replacing heroin use with non-pharmaceutical fentanyl “poses unique challenges for public health and treatment professionals “. He said doctors were reporting problems with patients experiencing delayed or precipitous withdrawal as they were induced with buprenorphine.

“New strategies to reduce mortality among opioid users are urgently needed,” Bisaga wrote. “Research programs must be established to quickly generate evidence to guide interventions targeting people affected by the influx of fentanyl.”

Kalfas, who is certified to treat up to 275 buprenorphine patients, said he has seen people with fentanyl in their system for days after their last use of the drug. Avoiding withdrawal when they start medication can be a struggle, she said, and if they don’t get through the wait, their desire to get help is destroyed and they’re back in danger of overdosing. It can be even worse to induce buprenorphine if it is too early to do so safely.

“Once I rush them severely enough, I’ve lost them,” Kalfas said. “I’ve lost their trust, I’ve pushed them back in their decision-making, and they tend to leave if they rush in here.”

Here’s what else Kalfas had to say about our questions about fentanyl

Answers have been edited for brevity and clarity.

Some patients report having trouble coming off fentanyl weeks after not using it. Is this possible?

Traveler: Yes. Norfentanil is a major metabolite of fentanyl that does not cause euphoria. It can remain in the receptors of the central nervous system for weeks. It is barely detectable.

Have you ever seen a patient take fentanyl pills by mistake, thinking it was a prescription drug?

traveler: Yes. For example, I had a guy come in and he said he took a “couple of oxys” for a back problem. I said, “That’s weird, there’s no oxycodone in the urine.” It’s all fentanyl. The patient was stunned.

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Does Journey Recovery see a lot of people who primarily use fentanyl?

traveler: Yes. Every provider has new patient (buprenorphine) induction appointments every day.

If I have made an appointment to start treatment for opioid use disorder, how long will it take to get one?

traveler: Usually, if you call in the morning, we get you in the afternoon.

Do you think the treatment of addiction disorders needs to change?

traveler: Yes. The treatment must evolve with the evolution of use. When we saw heroin, we wanted to treat heroin. When we see fentanyl, we want to treat fentanyl. We are always playing catch. We need to treat addiction, not just addiction to a particular drug.

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