In light of the Senate Finance Committee Hearing on May 23 titled: “Front Lines of the Fentanyl Crisis: Supporting Communities and Combating Addiction through Prevention and Treatment”, we asked Dr. Benjamin Nordstrom, who has been treating opioid addiction since 2005, to share some of the current challenges of treatment and the importance of comprehensive programs to address fentanyl addiction.
Q1: Can you discuss the scope of the problem regarding fentanyl addiction?
Dr. Nordstrom: The misuse of high-potency synthetic opioids (HPSOs) like fentanyl has become a significant issue, and they are now the most common drugs involved in drug overdose deaths in the United States. More than two thirds (68%) of the reported 107,081 drug overdose deaths in 2022 involved illicitly manufactured fentanyl. These alarming statistics highlight the urgent need for effective treatment programs.
Q2: What makes it more difficult to treat patients who are addicted to fentanyl compared to heroin?
Dr. Nordstrom: Patients using fentanyl need higher total doses for treatment, but these doses must start lower and be adjusted incrementally. For example, a patient may need 150 mg of methadone but must begin with 40-50 mg, requiring frequent adjustments— Even adjusting by 20mg/day means 5-6 adjustments over a couple weeks. This increases the number of visits with the provider and assessments needed to safely manage their treatment. Additionally, the higher the dose, the greater the risk of overdose, which complicates treatment further.
Q3: Why is the opioid treatment program (OTP) model important for getting patients on the path towards recovery?
Dr. Nordstrom: The OTP model, which provides medication-assisted treatment (MAT), including medication, counseling, psychosocial support and nursing care, is crucial for managing HPSO addiction. Methadone, the most commonly dispensed medication at OTPs, is a long-acting opioid with a half-life of 24 to 36 hours, so it accumulates in the body and can cause delayed toxicity. This necessitates accurate dose adjustments and regular patient engagement during the induction to ensure patient safety and engagement.
The induction phase for methadone can take at least 2 weeks to reach a therapeutic dose, and many patients need 8-12 weeks to stabilize. During this period, patients often feel unwell and are more likely to use excess medication or other substances, increasing the risk of fatal outcomes. Therefore, frequent patient encounters, thorough assessments, and a multidisciplinary care team are essential to address the nuances of addiction and provide comprehensive support.
Even in buprenorphine treatment, transitioning patients from fentanyl requires regular monitoring. The complexities of methadone’s pharmacodynamics further underscore the need for consistent oversight during induction and stabilization.