The Curbsiders Internal Medicine Podcast #24 Treating OUD in the Fentanyl Era: ASAM Treatment Week with Dr. Melissa Weimer
Oct 17, 2023
Dr. Melissa Weimer, a board-certified physician in addiction medicine and medical director at Yale, shares vital insights on treating opioid use disorder in the challenging fentanyl era. She emphasizes the importance of prescribing methadone and buprenorphine, while discussing initiation strategies and common pitfalls. Weimer also highlights the significance of personalized care, understanding precipitated withdrawal, and strategies for managing high-dose buprenorphine safely. Her passion for addiction care and commitment to reducing stigma shines through.
AI Snips
Chapters
Transcript
Episode notes
Manage Acute Pain And Withdrawal Aggressively
- Use higher short-acting opioid doses (e.g., oxycodone 15–25 mg q3h PRN) for patients with high fentanyl tolerance.
- Always hold for sedation and pair with clonidine, hydroxyzine, sleep aids, and avoid excessive benzodiazepines.
Methadone Titration Schedule
- Titrate methadone by ~10 mg/day: day1 40, day2 50, day3 60, then wait 3–5 days before further increases.
- Use short-acting opioids and non-opioid adjuncts while titrating, and monitor for sedation and QTc.
Case: Methadone To Buprenorphine Transition
- Ms G started methadone, stabilized, but later stopped due to lack of transportation to clinic and resumed fentanyl.
- She then attempted buprenorphine at home, tried 4 mg, and felt very sick, prompting a clinic restart.