Fentanyl assisted treatment: a possible role in the opioid overdose epidemic?

Abstract

BackgroundThe current opioid overdose epidemic affecting communities across North America is increasingly driven by illicitly manufactured fentanyl and its related analogues. A variety of public health interventions have been implemented and scaled up, including opioid agonist treatments (OAT). While these treatments are successful for many individuals, they have a variety of limitations. It is critical to trial alternative treatments if conventional opioid agonist treatment options are not successful for a proportion of patients who use illicit fentanyl.Main bodyPrescription fentanyl has been widely used for pain management. The use of transdermal fentanyl, specifically, which provides long acting and stable drug levels post-titration over several days, should be explored as an opioid agonist treatment option. The use of transdermal fentanyl for patients who use illicit fentanyl is currently being piloted in Vancouver, Canada. To address potential diversion, the patch is signed, dated, and a film dressing is applied to mitigate tampering. Evaluation outcomes are still pending, but there have been no adverse outcomes thus far and clinical improvements have been noted for many patients. This exploratory therapeutic approach should be considered across multiple settings and rigorously evaluated.ConclusionsThere are known limitations to existing OAT options and there is a need to urgently evaluate alternative strategies for patients who are using illicit fentanyl not successfully treated with conventional OAT. Many patients may be attracted to, and retained in, fentanyl assisted treatment. This may be another strategy for certain patients to prevent harms caused by illicit fentanyl use, including overdose and death.

Risk mitigation guidance and safer supply prescribing among young people who use drugs in the context of COVID-19 and overdose emergencies

“…Prescribers may worry about the limited evidence for the efficacy of RMG and other emerging safer supply programs (e.g., fentanyl patches – see below), and whether they have adequate training and experience to support careful opioid prescribing ( Young et al, 2022 ), while also feeling desperate to decrease morbidity and mortality in the context of dual public health emergencies through whatever means necessary. Currently in BC, fentanyl-assisted treatment via fentanyl patches is being increasingly offered to those who have received an OUD diagnosis and continue to be at high risk for drug toxicity-related harms despite having tried OAT, including those under the age of 19 ( Bardwell et al, 2019 ; BCCSU, 2022d ). This approach is more consistent with what the YPWUD who participated in this study said that they wanted and needed in order to reduce risks and harms.…”

Case report: acute care management of severe opioid withdrawal with IV fentanyl

“…This is analogous to using diacetylmorphine ("heroin-assisted treatment") which is currently regulated in several European countries and Canada, and has been proven more clinically effective and cost-effective than oral methadone for individuals with treatment-refractory OUD [ 41 , 42 ]. Moreover, though fentanyl patches are being explored for treatment as MOUD in Vancouver, this is largely experimental and there is relatively limited basis for this currently [ 19 ]. Large scale clinical research efforts are urgently needed, while also considering the medical and legal implications of such interventions.…”

“…Treatment protocols in a hospital setting can therefore adapt to better address the needs of patients who use fentanyl, given the increased opioid requirements experienced by this patient population [ 18 ]. Exploring the use of high-potency opioids such as fentanyl in withdrawal management and treatment for severe OUD is an immediate priority and calls for significant clinical research efforts [ 10 , 19 – 21 ].…”

Provider experiences with relaxing restrictions on take-home medications for opioid use disorder during the COVID-19 pandemic: A qualitative systematic review

“…Individuals whose needs are not met by OAT may benefit from treatment with injectable diacetylmorphine or hydromorphone ( Ferri et al, 2011 ; Oviedo-Joekes et al, 2016 ). Other alternatives, including fentanyl patches and hydromorphone tablets, have been provided to people who use substances as a public health measure ( Bardwell et al, 2019 ; British Columbia Centre on Substance Use, 2023 ; Brothers et al, 2022 ; Olding et al, 2020 ; Young et al, 2022 ). This practice has been termed “safer supply” ( Health Canada, 2021 ).…”