74. Quick-Start Injectable Buprenorphine74. Quick-Start Injectable Buprenorphine
Addiction Medicine Journal Club
Dr. Sonya Del Tredici and Dr. John Keenan review a large trial comparing rapid versus standard induction to injectable buprenorphine for people using fentanyl and other opioids. They explain the study design, results and safety, and share how the findings are already changing their approach to starting treatment.
30:37•20 Apr 2026
Quick-Start Injectable Buprenorphine and Fentanyl: Faster Paths Into Treatment
Episode Overview
- A rapid protocol using just one 4 mg sublingual dose before injectable buprenorphine led to higher treatment retention than the standard seven-day lead-in.
- The benefit of rapid induction was especially marked for people who tested positive for fentanyl and were using opioids nearly every day.
- Safety outcomes and serious adverse events were similar between rapid and standard induction, though withdrawal symptoms were common in both groups.
- The trial included many people with polysubstance use, making the findings more applicable to typical clinical practice.
- Both hosts describe using this evidence to offer rapid-start injectable buprenorphine to patients who are fearful of precipitated withdrawal and delays in care.
“I have patients all the time that come to me and they really keep coming back, but they haven't even started the medication because they're just so scared of precipitated withdrawal, especially in this fentanyl era.”
What insights can experts and survivors share about addiction? This episode of Addiction Medicine Journal Club zeroes in on a very practical question for opioid treatment: how quickly can someone start injectable buprenorphine, especially in the era of fentanyl? Dr. Sonya Del Tredici and Dr. John Keenan chat late at what they jokingly call “geezer midnight”, bringing a mix of solid science and dry humour to a very serious topic.
A randomised clinical trial from JAMA Network Open compared a standard seven‑day sublingual buprenorphine lead‑in with a rapid method that uses just one 4 mg sublingual dose before the first extended‑release injection. They walk through the study design in plain language, highlighting that more than 700 adults with moderate to severe opioid use disorder were involved, most using fentanyl almost daily and often alongside stimulants.
For people curious how clinicians think about evidence, it’s a clear look at how research translates into real decisions. Key findings matter for anyone affected by opioid use: the rapid start approach led to better treatment retention, especially for people testing positive for fentanyl, with similar safety outcomes.
As John puts it, “I have patients all the time that come to me and they really keep coming back, but they haven't even started the medication because they're just so scared of precipitated withdrawal, especially in this fentanyl era.” Sonya shares how this trial has already shifted her own practice and given anxious patients another option.
Although the show is aimed mainly at clinicians and offers CME credit, people in recovery or supporting loved ones may appreciate hearing how carefully these medications are studied and how quickly practice can change. If faster access to effective treatment can keep more people alive and engaged, what could this kind of rapid start mean for the future of opioid recovery?
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