Mary Figgatt is a postdoctoral fellow at the Miriam Hospital in Rhode Island, USA. She is an epidemiologist who studies emerging topics affecting people who use drugs and the impact of community-based programs.

Fentanyl in the North American drug supply has led to surges in overdoses while simultaneously introducing complications in opioid agonist treatment (OAT). Specifically, fentanyl’s lipophilic properties may cause precipitated withdrawal among those starting buprenorphine/naloxone. To examine the patterns of OAT use and precipitated withdrawal in the era of fentanyl, we conducted a survey among participants accessing a community drug checking service in Rhode Island, USA during 2023-2024. This sub-analysis included those reporting a lifetime history of fentanyl/heroin use. Variables assessed included drug use history, use of OAT, and experiences with precipitated withdrawal (defined by describing symptoms and severity). Drug checking data were used to describe fentanyl prevalence among participants’ drug samples. During the study period, 94% of suspected street opioid samples contained fentanyl. Of the 191 participants, the median age was 41 years (interquartile range: 35-49), 60% were men, and 59% were non-Hispanic white. Participants’ lifetime history of methadone and buprenorphine was similar between the two medications (79% and 74%, respectively). However, use within the past 6 months varied by medication (52% for methadone and 20% for buprenorphine). Nearly half (42%) of people had experienced precipitated withdrawal in their lifetime; of those, 54% said it occurred while starting buprenorphine. When comparing the two medications, precipitated withdrawal was six times more common among those starting buprenorphine compared to methadone (30% versus 5%, respectively). Among the 7 people experiencing precipitated withdrawal in the past 6 months while starting buprenorphine, only 4 were still on buprenorphine. Precipitated withdrawal while starting buprenorphine is a concern that is complicated by fentanyl. People interested in starting OAT should be provided with options that are best suited for their individual needs and within the context of the changing drug supply.