“You’re Hoping for the Best, but Preparing for the Worst”: Discussions of Starting Buprenorphine in the Context of Fentanyl Use with Clinicians and People Who Use Fentanyl

Abstract Background Illicitly manufactured fentanyl has become the most prevalent opioid in the USA and accounts for the largest percentage of overdose events. Fentanyl has also complexified starting buprenorphine, a highly effective medication for treating opioid use disorder. This qualitative study explored the experiences of clinicians and people who use fentanyl (PWUF) starting buprenorphine in the context of fentanyl use. Methods Semi-structured interviews were conducted with clinicians and PWUF in the Seattle, WA, area. Interviewers inquired about substance use and treatment history, decision-making and sources of information related to MOUD, buprenorphine initiation logistics and experience, barriers and facilitators to starting buprenorphine, and insights and observations about treatment settings. Researchers used a rapid analysis process to analyze the data. Results Analysis included 43 participants (15 clinicians, 28 PWUF). Clinicians had a mean age of 40 years, were 53.3% male, and were 93.3% White. PWUF had a mean age of 44 years, were 66.6% male, were 46.4% white, and were 32.1% Black/African American. The prominent themes were (1) Fear of withdrawal, both precipitated and otherwise, was a top concern when starting buprenorphine in the context of fentanyl; (2) In the fentanyl era, there is no longer a one-size-fits-all approach to buprenorphine initiation, leading to uncertainty among both clinicians and PWUF; (3) Starting buprenorphine was hampered by easy access to cheap fentanyl; and (4) PWUF reported successful buprenorphine starts were facilitated by their own mindset and determination. Conclusions While both PWUF and clinicians identified precipitated withdrawal as a major concern when initiating buprenorphine, it was just one of many barriers. More research is needed in order to provide clinicians with accurate, up-to-date guidance on starting buprenorphine. As we aim to provide buprenorphine to more people, it will be important to engage with PWUF to identify and address real-world barriers.