Considerations for implementing high-dose buprenorphine for opioid use disorder

Stringfellow et al. [1] investigated the association between higher doses of buprenorphine and treatment retention for patients with opioid use disorder (OUD) using a national, multi-payer cohort. In their observational cohort study analyzing data from 498 879 patients in the USA receiving treatment for OUD, they found that higher doses of buprenorphine–naloxone (24 mg, 32 mg and 40 mg) were associated with increased retention in treatment at 1, 6, 12 and 18 months. Their findings further substantiate the clinical utility of high-dose buprenorphine in improving treatment retention – a crucial consideration given that relapse rates remain high, with 40%–50% of patients returning to opioid use within 6 months of initiation [2]. This is especially relevant in the context of a fentanyl-dominated illicit drug supply, where the heightened potency of fentanyl-involved overdose mixtures often necessitates more intensive treatment strategies [3]. We commend Stringfellow et al. for strengthening the evidence base for high-dose buprenorphine and its role in OUD treatment. If implemented thoughtfully, it could play a vital role in improving treatment retention and reducing opioid-related mortality.

The Veterans Health Administration (VHA) offers a valuable case study for guiding real-world implementation. As one of the largest integrated healthcare systems, the VHA has been at the forefront of piloting higher doses of buprenorphine into clinical pain management. Since 2013, the proportion of VHA patients receiving doses exceeding 24 mg/day has steadily increased, largely driven by revisions to VHA/Department of Defense pain management guidelines that allow greater prescribing flexibility [4].

However, we believe that two key barriers must be addressed to facilitate broader adoption. First, restrictive insurance policies and inconsistent Medicaid coverage could disproportionately limit access for marginalized populations, particularly individuals with fentanyl exposure who may require higher doses for effective stabilization. Without greater parity in reimbursement, the patients who stand to benefit most may be unable to receive optimal care. Second, clinician hesitancy remains a major hurdle. Many providers may be unfamiliar or uncomfortable prescribing doses above 16 mg due to concerns over liability, regulatory scrutiny, or potential stigma associated with higher doses. Overcoming this hesitancy requires structured provider education, updated clinical guidelines, and institutional support to promote adoption. The VHA's approach – revising prescribing guidelines to enable dose escalation based on patient response – serves as a model that could be adapted across healthcare settings. Future efforts should also focus on system-level policies, such as expanding insurance coverage, clinician training, and risk mitigation strategies, to ensure safe and equitable access.

Amidst the opioid crisis and the sheer number of lives that have been lost, expanding access to higher-dose buprenorphine holds promise. More research is needed to fully understand its potential, but it is crucial that healthcare systems begin to consider this option and its potential in saving numerous lives.

Suhanee Mitragotri: Conceptualization (equal); writing—original draft (lead). David T. Zhu: Conceptualization (equal); writing—review and editing (lead).

N/A.

None to declare.