79. Direct-to-Inject Buprenorphine79. Direct-to-Inject Buprenorphine
Addiction Medicine Journal Club
Two addiction doctors review research on starting long-acting injectable buprenorphine without a test dose and share real-world retention and withdrawal data. They also talk through current substance use policy shifts, surveillance ideas, and the practical challenges of using these treatments in everyday clinical practice.
31:43•13 Jul 2026
Direct-to-Inject Buprenorphine: A Simpler Path for Fentanyl Users?
Episode Overview
- Direct-to-inject buprenorphine without a sublingual test dose showed good tolerability and 43% retention at 90 days in a largely unhoused, high-risk group.
- Around 37% of patients reported no withdrawal and severe withdrawal was uncommon, challenging fears that injections always trigger precipitated withdrawal.
- Current U.S. policy proposals include reduced harm reduction funding and pressure to taper opioid use disorder medications, raising concerns among addiction clinicians.
- Wastewater monitoring, AI tools, and faith-based recovery farms are being discussed as future drug strategy components, with mixed views on ethics and usefulness.
- Clinicians face practical hurdles using long-acting injectables, including medication access, clinic logistics, and colleagues’ reluctance to adopt new protocols.
“The dose most guaranteed to give you precipitated withdrawal is the one we’re supposed to give right before the long-acting injection.”
Curious about how others manage opioid addiction in the age of fentanyl? Addiction Medicine Journal Club pulls apart the data on "direct-to-inject" buprenorphine and what it might mean for real people trying to stay alive and engaged in care. Dr John Keenan and Dr Sonya Del Tredici chat in an easy, collegial style, mixing weekend baseball games and garden mulch with hard science. After a quick tour of current U.S.
substance use policy using the KFF health policy tracker and a CBS News piece on the proposed national drug strategy, they talk frankly about concerns over cutting harm reduction funding, pressure to taper medications for opioid use disorder, and the risk of vilifying SSRIs despite evidence of benefit. The heart of the episode is a case series on starting long‑acting injectable buprenorphine without a sublingual test dose.
For patients using fentanyl, that test dose can be "the dose most guaranteed to give you precipitated withdrawal," so the team highlight a protocol where people stop fentanyl briefly, receive a weekly buprenorphine injection, and can still use adjunct meds or even fentanyl during the first 24 hours. In a largely unhoused, high‑risk cohort, 43% were still in treatment at 90 days and, as Sonya notes, "37% had no withdrawal at all," with severe withdrawal remaining relatively uncommon.
They also weigh up practical barriers: buy‑and‑bill issues, patchy clinic schedules, and colleagues hesitant to use long‑acting injections. A listener comment about a Swedish registry study on first opioid prescriptions adds an extra layer, raising questions about how risk scores miss crucial social factors like school performance and parental divorce. If you're a clinician, student, or policy‑curious person wanting research you can actually use in addiction practice, this episode keeps things honest, data‑driven, and oddly hopeful.
Could direct‑to‑inject buprenorphine be the simpler option your patients have been waiting for?
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