Dosing Buprenorphine in the Fentanyl Era

Fentanyl is 50-times more potent than heroin, drastically raising the rate of overdose deaths

In the fentanyl era, going above the standard buprenorphine dose may keep patients in treatment without added danger

STUDY: Chambers L et al, International Journal of Population Data Science 2026

STUDY TYPE: Retrospective cohort study

FUNDING: Independent

Background

We learned how to dose buprenorphine (eg, Suboxone) before fentanyl, and have little research to guide us in the fentanyl era. Fentanyl is 50-times more potent, leading to more withdrawal problems and greater overdose risk. Anecdotally, some recommend dosing buprenorphine above the standard 16 mg/day ceiling. This study tests that idea with real-world data.

The Study

• 8,676 Rhode Island residents starting buprenorphine for opioid use disorder between October 2016 and September 2022, linked across five state databases covering prescribing, emergency medical services, medical examiners, vital records, and behavioral health treatment.
• Compared overdose risk on days with versus without active buprenorphine treatment over the following year.
• Compared time to treatment discontinuation over 180 days for patients started at 16 mg versus 24 mg.

Results

Starting on the 16 mg dose was linked to a 20% higher discontinuation rate compared to 24 mg (adjusted hazard ratio 1.20, 95% CI 1.06–1.37).

Overdose risk was 61% lower on days patients were taking buprenorphine compared to days they weren’t (adjusted risk ratio 0.39, 95% CI 0.31–0.49). Doses didn’t differ between overdose days and non-overdose days, so higher doses weren’t tied to more overdoses.

Limitations

Observational data, so doesn’t control for confounders. Though large, the data comes from only one state in the US.

Practice Implications

1. Buprenorphine keeps protecting against overdose even in the fentanyl era, and that protection depends on patients staying on it.
2. If a patient on 16 mg is still struggling with cravings or early dropout, this data supports titrating up toward 24 mg rather than holding the line at the old ceiling.