As fentanyl reshapes opioid use disorder treatment, long-standing buprenorphine induction practices are being challenged. In this episode, we examine emerging evidence supporting rapid, same-day initiation of long-acting injectable buprenorphine, alongside the growing role of high-dose transmucosal buprenorphine for fentanyl use disorder. We discuss why traditional multi-day inductions may increase dropout without improving safety—and how rapid initiation can improve early retention, including among patients actively using fentanyl.

We also explore when and why higher buprenorphine doses may be necessary to adequately suppress withdrawal and cravings in the fentanyl era. We cover common misconceptions about precipitated withdrawal, and key contraindications and protocol caveats.

Designed for addiction fellows and frontline clinicians, this episode emphasizes a shift from withdrawal-centric rituals to retention-focused care—getting effective treatment started when it matters most. Hosted by Paula Donnelly Cook, MD and Darlene Petersen, MD.

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