Managing Opioid Withdrawal Symptoms During the Fentanyl Crisis: A Review

Area of Science:

• Addiction Medicine
• Pharmacology
• Public Health

Background:

• Illicitly manufactured fentanyl (IMF) drives rising overdose deaths.
• IMF's potency and lipophilicity complicate opioid withdrawal syndrome (OWS) and opioid use disorder (OUD) management.
• Current OWS management strategies for individuals using unregulated opioids require synthesis.

Purpose of the Study:

• To review therapeutic interventions for OWS and OUD management in individuals using unregulated opioids, focusing on IMF.
• To identify effective treatments published between January 2010 and November 2023.

Main Methods:

• Systematic literature search conducted by a health science librarian.
• Screened 426 studies, reviewed 173 at full-text.
• Included 49 studies meeting eligibility criteria.

Main Results:

• Buprenorphine and naltrexone were common, often transitioning to long-acting injectables.
• Adjunctive medications (buspirone, memantine, suvorexant, gabapentin, pregabalin) and rapid initiation showed positive results.
• Lofexidine, gabapentin, and suvorexant have limited evidence for augmenting opioid agonist initiation outside FDA-approved OUD medications.
• Neurostimulation showed promise but was studied early.
• Precipitated withdrawal rates were low and manageable with buprenorphine induction.
• Maintenance treatment is superior to detoxification alone.

Conclusions:

• Shorter induction protocols facilitate quicker access to evidence-based OUD treatment.
• Liberal use of adjunctive medications and rapid initiation are key to effective OWS management.
• Continued maintenance treatment is crucial for long-term OUD recovery.