Inadequate Dosing in Opioid Addiction Treatment Can Result in Fentanyl Overdoses

In the ongoing battle against opioid addiction, a critical issue has emerged: the potential dangers of underdosing patients during treatment. Underdosing can lead to severe consequences, including increased cravings for illicit substances like fentanyl, which is known for its potency and risk of overdose.

Consider a scenario where a patient, who we will call Rosa, experiences vivid dreams about using fentanyl after starting a treatment program for her opioid use disorder. Despite successfully beginning treatment with buprenorphine--a medication aimed at alleviating withdrawal symptoms--Rosa struggles with persistent cravings and unsettling dreams of using fentanyl. Her plea for a higher dosage reflects a common challenge faced by many patients in similar situations.

Buprenorphine, which has been used in the United States since its approval in 2002, is often prescribed at a target dose of 16 milligrams, a guideline that has remained largely unchanged for two decades. This prescribing standard is based on the belief that higher doses may lead to misuse. However, many patients continue to experience withdrawal symptoms and cravings even at this prescribed level, highlighting a significant gap in treatment.

Research indicates that a considerable number of patients may require doses exceeding the standard 24 milligrams to effectively manage their addiction. In my experience as a family physician specializing in addiction medicine, I have seen firsthand how increasing the dose of buprenorphine can be a matter of life or death for patients who are at risk of relapsing into addiction.

While some patients may misuse their medication, studies consistently show that individuals often obtain additional buprenorphine to manage withdrawal symptoms rather than for recreational use. It is essential to recognize that higher dosing can significantly improve treatment outcomes for many individuals, especially as fentanyl has increasingly infiltrated the opioid market.

Fentanyl, which is approximately fifty times more potent than heroin, poses unique challenges for those in recovery. Low doses of buprenorphine may not suffice to counteract its effects, increasing the risk of relapse and overdose. As a result, finding the correct dosage is crucial in the treatment process.

Medicaid programs in several states have begun covering higher doses of buprenorphine, yet many health insurers and state laws still impose restrictions. This inconsistency can hinder access to effective treatment and exacerbate the risks associated with opioid addiction.

In light of the evolving landscape of opioid use, a petition was submitted to the FDA in 2022, advocating for a reconsideration of buprenorphine dosing guidelines. In December 2023, a consensus among addiction experts affirmed that benefits exist at doses beyond the previous maximum recommendation. This led to a significant update in the FDA's guidelines in December 2024, eliminating the fixed target dose and acknowledging the evidence supporting higher doses.

As the nation grapples with the opioid crisis, ensuring that patients receive adequate treatment is more important than ever. Inadequate dosing not only undermines recovery efforts but can also lead to tragic outcomes, including relapse and overdose. Buprenorphine, when prescribed at the correct dosage, is a life-saving medication that can help individuals reclaim their lives from the clutches of addiction.