Straight to the Shot: A New Way to Quit Fentanyl and Start BuprenorphineStraight to the Shot: A New Way to Quit Fentanyl and Start Buprenorphine
Addiction Medicine Made Easy
Dr Casey Grover explains a direct-to-inject buprenorphine protocol using weekly Brixadi and monthly injections to ease fentanyl transitions and reduce withdrawal. The episode outlines practical steps, comfort medications, and real-world experiences from addiction medicine practice in acute and street-based settings.
33:10•30 Mar 2026
Straight to the Shot: Making Buprenorphine Starts Easier in the Fentanyl Era
Episode Overview
- Fentanyl behaves more like methadone than heroin, making traditional buprenorphine starts much riskier for precipitated withdrawal.
- Microdosing buprenorphine can work well but often demands high levels of organisation and support that many patients do not have.
- Weekly Brixadi can act as an automatic microdose over 24–48 hours, easing people onto buprenorphine while they briefly continue fentanyl use.
- Comfort medications such as clonidine, ondansetron, and hydroxyzine can significantly reduce withdrawal symptoms during the transition.
- Monthly injections like Sublocade or monthly Brixadi reduce daily pill decisions and, in Sublocade’s case, can provide a very gradual taper off buprenorphine.
“Once that shot’s in your body, you can’t go back. It’s a commitment to actually making the transition from whatever opioid people are on, usually fentanyl, to buprenorphine.”
Curious about how others manage their sobriety journey when fentanyl is in the mix? This episode of *Addiction Medicine Made Easy* breaks down a hands-on, clinic-tested way to get people off fentanyl and onto buprenorphine with far less misery: a direct-to-inject approach using long-acting buprenorphine shots. Dr Casey Grover sets the scene by comparing the “heroin years” with the fentanyl era. Back then, many people could wait 12 hours, take suboxone, and feel better.
Fentanyl, though, behaves more like methadone – it hangs around in fat tissue, sticks in the system, and makes standard inductions a minefield of precipitated withdrawal. As he puts it, starting buprenorphine too early is “like going from 100 miles an hour to 60 miles an hour. It’s like slamming on the brakes.
You feel that difference.” From there, he walks through microdosing strategies and why they can be so hard for people whose executive functioning is already under strain from addiction. Cutting strips into eighths, remembering complex schedules, and managing fear of withdrawal is a big ask for anyone, never mind someone in active opioid use. That’s where weekly Brixadi comes in.
Grover explains how a once-weekly injection acts like an automatic microdose over 24–48 hours, letting people keep using fentanyl briefly before switching fully to buprenorphine with support meds such as clonidine, ondansetron, and hydroxyzine. After a week, many transition to a monthly shot of Sublocade or monthly Brixadi to reduce cravings and cut the daily decision-making around pills.
Along the way, he shares real-world experience from colleagues using this protocol on the street and in homeless outreach, plus a clever use of Sublocade’s long “tail” to taper people off buprenorphine without noticeable withdrawal. If you’re working in acute care, supporting someone on opioids, or just want to understand modern buprenorphine starts in the fentanyl era, this one might reshape how you think about withdrawal and induction—could a single shot be the easier start someone needs?
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