JAMA Clinical Reviews Medications for Opioid Use Disorder, Withdrawal, and Overdose
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Feb 11, 2026 Alexander Walley, a Boston University professor and addiction medicine clinician, walks through medications for opioid use, withdrawal, and overdose. He explains how buprenorphine works and its formulations. He compares methadone and buprenorphine, covers naltrexone initiation challenges, details withdrawal timelines and treatments, and reviews naloxone routes and community dosing.
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Preventing Precipitated Withdrawal
- Avoid initiating buprenorphine too soon after last opioid use to prevent precipitated withdrawal.
- With fentanyl, wait longer (sometimes up to 72 hours) before starting buprenorphine.
Methadone's Role And Mortality Benefit
- Methadone is a long-acting full agonist that treats withdrawal, reduces cravings, and can block other opioids once stabilized.
- It has strong evidence for reducing overdose and all-cause mortality.
Safe Methadone Initiation And Titration
- Start methadone at lower doses (historically 30–40 mg) and titrate slowly to maintenance (often ≥80–100 mg).
- In fentanyl users consider higher initiation and titration; some patients need >200 mg for control.