Implementation of Low-Dose Buprenorphine Induction at a Syringe Services Program: A Pilot Study

Background: Fentanyl’s penetration into the unregulated drug supply has complicated the treatment of opioid use disorder (OUD), particularly by increasing the risk of buprenorphine-precipitated opioid withdrawal (BPOW). Buprenorphine, a partial opioid agonist, remains a first-line treatment for OUD, but traditional induction methods can be intolerable for people using fentanyl. Low-dose induction (LDI), a strategy characterized by gradual buprenorphine titration without prior withdrawal, has emerged as a promising alternative to mitigate BPOW. However, the feasibility and acceptability of LDI in low-barrier, real-world settings such as syringe services programs (SSPs) remain underexplored. Methods: We conducted a mixed-methods prospective cohort study from June 2023–2024 at an SSP in Miami, Florida, offering a 4-day LDI protocol to patients with OUD who were interested in starting buprenorphine. Follow-up, conducted on a walk-in basis within four weeks, included urine drug screens (UDS), symptom surveys and semi-structured qualitative interviews. The primary outcome was successful buprenorphine initiation, defined by a positive UDS for buprenorphine at follow-up. Results: Of the 30 participants enrolled in the 4-day LDI protocol, most (n=29) had prior buprenorphine experience and nearly 90% (n=26) reported past BPOW. Only 16 (53%) returned for follow-up. Nine (56%) of those followed up tested positive for buprenorphine, 11 (68.8%) reported that LDI worked for them, and 12 (75%) said they would use the method again. Qualitative interviews revealed six key themes: 1) LDI mitigates withdrawal symptoms; 2) instructions were helpful but could be improved; 3) fear of BPOW motivated LDI use; 4) LDI enabled autonomy in recovery; 5) unstable living environments hindered adherence; and 6) LDI allowed participants to maintain social roles. Conclusions: While only 30% of the cohort had objective evidence of buprenorphine induction, most reported successful attempts and found LDI acceptable and empowering. High loss to follow-up and environmental instability limited our conclusions in this outpatient harm reduction setting. These findings underscore the potential of LDI to reduce barriers to buprenorphine use, especially when adapted to real-world constraints. Further research is needed to refine LDI protocols and address the structural determinants affecting treatment success among people who use fentanyl.