Treatment for Substance Use Disorder in the Synthetic Opioid Era
Treatment for Substance Use Disorder in the Synthetic Opioid Era https://pediatricsnationwide.org/wp-content/uploads/2025/02/082423BS0101.jpg 1024 683 Alaina Doklovic Alaina Doklovic https://pediatricsnationwide.org/wp-content/uploads/2023/11/100923RH0019-e1699635391623.jpg- February 04, 2025
- Alaina Doklovic

Medications for opioid use disorder (MOUD) is the recommended first line treatment for adolescents with opioid use disorder (OUD), the chronic use of opioids and/or synthetic opioids that causes clinically significant distress or impairment.
Buprenorphine is the most accessible medication for MOUD. Studies show long-term use of buprenorphine decreases opioid use, reduces overdose risk and increases treatment retention. Adolescents can continue to go to school or work while taking this medication.
With the introduction of synthetic opioids such as fentanyl, buprenorphine stabilization in the synthetic opioid era looks a little different. Fentanyl is lipophilic, meaning it may be retained in the body for a longer period of time. Prolonged use of fentanyl can also result in a higher volume of distribution throughout the body and slower dissipation. Because of this, the standard practice of administering buprenorphine is more likely to precipitate withdrawal in patients who use synthetic opioids. Symptoms of precipitated withdrawal are intense and can include restlessness, sweating or anxiety.
To combat this, administering higher doses of buprenorphine, called macrodosing, while the patient is in mild withdrawal will produce quick stabilization. Another treatment option is microdosing, where low doses of buprenorphine are administered with opioid continuation across 7 days. This helps prevent precipitated withdrawal.
In this new era, there is a smaller window to intervene after synthetic opioid use because of how fast fentanyl enters the central nervous system. Higher doses of naloxone than normal may be needed.
“We want patients with opioid use disorder to have the best medication to treat OUD,” says Erin McKnight, MD, MPH, adolescent medicine and addiction medicine physician and medical director of the Substance Use Treatment and Recovery Program at Nationwide Children’s Hospital. “It’s important to make them feel better from a withdrawal standpoint and get their cravings under control so they can get back to living their normal life. The goal is for them to wake up every morning feeling healthy and confident.”
Need for More Providers to Prescribe MOUD
Despite research showing the benefits of MOUD, this treatment is not reaching adolescents. According to a study in Pediatrics, the rate of buprenorphine dispensed to adolescents decreased 25% from 2015-2020.
Dr. McKnight also conducted a study on office-based buprenorphine access in Ohio before the removal of an X waver training requirement and license required to administer buprenorphine to treat substance use disorders. Her study found less than half of 1,828 waivered providers in Ohio in 2018 were prescribing buprenorphine. About a quarter of Ohio counties had no buprenorphine access.
However, as of April 2021, pediatricians do not need a waiver to prescribe buprenorphine. This should increase the accessibility of buprenorphine and allow providers to feel comfortable prescribing it as treatment for OUD, especially when synthetic opioids are being used.
“Treatment should be available to everyone for opioid use disorder,” says Dr. McKnight. “Medication treatment of opioid use disorder is the first line evidence-based treatment, and we need to decrease any barriers that may be present to get people the life-saving medication they need.”
When providing treatment to a patient for the first time, pediatricians should discuss expectations and how treatment for precipitated withdrawal will be before the start, says Dr. McKnight. Once a patient is stabilized with buprenorphine, patients no longer experience withdrawal and have minimal to no opioid cravings. Individuals that use synthetic opioids may have more difficulty achieving stabilization and require higher doses of buprenorphine.
This medication may be needed for life, but this is ultimately up to the patient, Dr. McKnight says.
“Some patients may need to take buprenorphine for the rest of their life. Others might not. It really is a shared decision between the patient and their doctor,” says Dr. McKnight. “We want our patients to get back to a space where they can live their life, where they can go to school, go to work and enjoy their family and friends again.”
About the author
Alaina Doklovic is a Marketing Specialist for Research Communications at Nationwide Children’s Hospital. She received her BS in medical anthropology and English from The Ohio State University. Her passions for science and health, combined with her desire to help others, motivated her to pursue a career in which she could actively help improve patient outcomes and scientific research through writing.
- Alaina Doklovichttps://pediatricsnationwide.org/author/alaina-doklovic/
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