Skip The Strip: Talking Direct to Inject for OUD With Dr. Reb CloseSkip The Strip: Talking Direct to Inject for OUD With Dr. Reb Close
Addiction Medicine Made Easy
Dr Casey Grover and Dr Reb Close talk through the Direct To Inject approach for moving people from fentanyl and other opioids onto buprenorphine, comparing it with macrodosing and microdosing options. The conversation focuses on real-world details like comfort meds, continued use of usual supply, and long-acting injectables in both clinic and street settings.
34:18•7 Sept 2026
Skip the Strip: Direct-to-Inject Buprenorphine in the Fentanyl Era
Episode Overview
- Transitioning from fentanyl to buprenorphine is high risk for precipitated withdrawal, so patients need clear explanations and genuine choice between macrodose, microdose, and DTI options.
- Direct To Inject uses weekly Brixadi as a built-in 24-hour microdose, with patients continuing their usual opioid supply during that period to reduce the chance of severe withdrawal.
- Comfort medications such as clonidine, hydroxyzine and ondansetron are given in limited quantities and framed as essential tools, not optional extras, to get through the transition.
- Access to a patient’s usual supply is treated as a safety issue in DTI; without it, Dr Close may postpone the injection to avoid avoidable suffering.
- Long-acting injectables like Sublocade are used after the DTI start to saturate receptors and provide a long protective tail, with lidocaine pre-injection helping make painful shots more tolerable.
“Once that first injection's in, if that person is ready for treatment, they're in. It's committed.”
How do different strategies aid in addiction recovery? This episode of *Addiction Medicine Made Easy* zeroes in on one of the toughest clinical challenges around opioids: getting someone from fentanyl to buprenorphine without putting them through hellish withdrawal. Host Dr Casey Grover sits down with Dr Reb Close, his colleague and spouse, to break down Direct To Inject (DTI) – a method that uses long-acting injectable buprenorphine from the outset.
As Dr Close puts it, "Once that first injection's in, if that person is ready for treatment, they're in. It's committed." Aimed mainly at emergency and acute care clinicians, the conversation walks through why fentanyl makes transitions so risky, with its long-acting, lipophilic build-up and high chance of precipitated withdrawal. You’ll hear clear comparisons between options like macrodosing, microdosing with and without cross-taper, and why many patients simply can't tolerate days of white-knuckle withdrawal.
DTI gets a detailed, practical breakdown: weekly Brixadi as a built-in 24-hour microdose, the expectation that patients keep using their usual supply during that first day, and the structured use of comfort meds like clonidine, hydroxyzine and ondansetron. Dr Close shares real-world street and clinic stories, from patients texting during transitions to sitting in the car while someone calls their dealer to make sure they can stay "normally well" during those critical 24 hours.
They also talk nuts-and-bolts technique: dosing strategies, switching from methadone, stacking monthly Sublocade for a strong "tail", and why a little lidocaine before injections can turn a dreaded shot into a non-event. Delivered with humour, honesty, and a strong harm-reduction focus, this conversation offers a grounded look at how clinicians are trying to make a brutal transition safer and more tolerable.
If you’re curious how modern addiction medicine is adapting to fentanyl-era realities, this might give you plenty to discuss with your team or support network.
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