Buprenorphine-naloxone (BUP-NX) is a life-saving treatment for opioid use disorder (OUD). Increasing use of illicitly-manufactured fentanyl (IMF), however, has made initiating BUP-NX more likely to precipitate withdrawal—an experience that can deter further BUP-NX treatment and cause return to use. Newer methods for outpatient BUP-NX initiation generally focus on reducing a patient’s risk of withdrawal by extending the time for complete transition to buprenorphine. As a necessary consequence, these approaches prolong exposure to fentanyl’s harms, taking a median of 8 days (range: 3-120 days) for those who are able to complete the transition (Adams, 2021).

We present a novel approach to rapid outpatient BUP-NX initiation. By choosing to self- administer 4 mg of intranasal naloxone, a patient was able to fully transition to a therapeutic dose of BUP-NX less than three hours after his last IMF use. After the naloxone, complete transition to buprenorphine took 31 minutes, including 18 minutes of expected withdrawal peaking at a COWS of 28. He remains in care with BUP-NX and would recommend this transition approach to others.

This initiation method could be a valuable option for patients in two ways: 1) no delay is required after their last IMF use and 2) they experience a much shorter transition to BUP-NX. Should patients choose this approach, they can have a predictably short period of withdrawal symptoms and stop ongoing exposure to fentanyl. This patient’s advice to other individuals considering this approach: “You will be sick for an hour and then you will be perfectly fine.”