Imagine a patient named Rosa telling you that she wakes up in moist sweat in her dream of smoked fentanyl.

Dreams seemed crazy to her. Three months ago, Rosa became pregnant and began to visualize as a good parent. She realized it was finally time to give up on her self-destructive use of fentanyl on the street. With great efforts, she began to use buprenorphine to treat opioid use disorders.

As hopefully, she felt very at ease with the painful symptoms of getting rid of the painful withdrawal symptoms (unset legs, anxiety, bone pain, nausea and chill) and got rid of the addiction, shame and difficulty. But even so, Rosa finds herself musing on the booming moments of Fentanyl all day, which seems more attractive. She couldn't escape those dreams at night.

Rosa asks your doctor about higher doses of buprenorphine. You think carefully about her request. Your clinic follows the Food and Drug Administration’s prescription guidelines, which have changed slightly over more than 20 years. It recommends her current prescription - 16 mg - as a "target" dose. You know the general view of healthcare providers is that most patients do not need to have a dose higher than that. Many people believe that patients or others will use extra pills to get height.

But after many visits, you will feel like you know Rosa very well. You believe in her sincerity. She is a responsible 25-year-old with a full-time job and never missed a date. After years of sofa surfing, she now has a stable housing with her parents. You reluctantly agree and increase her daily dose, adding another 8 mg of medicine, totaling 24 mg.

Rosa told you on her next visit that the higher dose resolved her daytime fentanyl craving, but the nightmare continues. She wanted to try a higher dose.

How should you respond? The FDA guidelines clearly state that there is no evidence to support any benefits above her new dose. You begin to doubt Rosa's sincerity and her own judgment.

The hazards of low doses

This hypothetical situation has been played countless times in the United States since 2002, when buprenorphine was first approved as a treatment for opioid use disorders. As a family doctor specializing in addiction medicine, I often encounter patients who experience withdrawal symptoms at “target doses” even at the maximum dose of 24 mg.

People like Rosa, those with uncontrolled fentanyl desires (whether awake or dreaming) are at high risk of leaving treatment and re-engagement. However, from 2019 to 2020, only 2% of the prescription for buprenorphine was only 24 mg.

I was able to help some of them as co-founders and medical directors of lower-level clinics, a clinic that makes it easier for people to start using buprenorphine. I request higher doses when our clinicians believe that current clinicians do not meet the needs of their patients.

Dosage selection may be a decision of life or death. Adding it to a drug (to 32 mg) will usually cause the patient to stay or leave treatment the difference. The risk of leaving treatment is particularly important for patients we usually see in low-sex clinics, many of whom face serious life challenges. Although patients do sometimes give up or sell additional pills, studies have always shown that illegally obtained drugs are most commonly used for self-treatment - to control withdrawal and withdraw from opioids when treatment is not available.

My Medicaid in Washington State began paying for a prescription fee of up to 32 mg in 2019. But clinicians may still encounter restrictions from other health insurance companies and pharmacies. Some states, such as Tennessee, Kentucky and Ohio, have restricted legal restrictions.

Find the correct dose

Starting in 2013, fentanyl has swept the country nationwide, and the challenge of finding the right dose of treatment has become even more acute. Fentanyl now dominates the opioid supply. Fentanyl is fifty times stronger than heroin, and it submerges the ability of low-dose buprenorphine to cope with its effects.

Buprenorphine (also known for its brand Suboxone) is a mixture of buprenorphine and naloxone - an opioid that not only activates opioid receptors in the brain, but also partially blocks them. It provides enough opioid effects to prevent withdrawal symptoms and desires, while also preventing the reward of euphoria. It relieves pain like other opioids, but does not cause respiratory arrest. It can greatly reduce the risk of excessive death by up to 70%.

In medicine, there is a widespread concern that too high doses may have toxic effects. However, as many clinicians and researchers have observed, using some therapeutic doses that are too low can also lead to harm, including death in patients returning to fentanyl.

After observing that so many patients respond well to higher doses, my colleagues and I looked for more information in the medical literature. In 1999, we found more than a dozen reports that provided evidence that the benefits of buprenorphine steadily increased to at least 32 mg.

At higher doses, patients have longer treatment time, less frequent use of illicit opioids, fewer complications of hepatitis, fewer emergency room visits and hospitalizations, and less suffering from chronic pain. Brain scans showed that 32 mg of buprenorphine accounted for more opioid receptors – more than 90% of the receptors compared to lower doses. One study even showed that a sufficiently high dose of buprenorphine could directly prevent fentanyl overdose.

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Patients with certain health conditions may particularly benefit from higher doses. During pregnancy, as is the case with Rosa, withdrawal symptoms increase as changes in metabolism reduce blood concentrations of most drugs. Higher doses may be required to maintain their pre-pregnancy impact levels. Additionally, I found that patients in my clinic who suffer from chronic pain, PTSD, or long-term opioid use are most likely to be relieved at a dose of over 24 mg.

The American Society of Addiction Medicine recommends four therapeutic goals: inhibit opioid withdrawal, block the effects of illicit opioids, block opioid cravings and reduce the use of illicit opioids, and promote recovery-oriented activities.

Similarly, patients seek comfortable and effective doses – i.e., dosages that avoid withdrawal symptoms and desires, and allow them to avoid illegal drug use and associated worries and stress. Many patients also desire to be trusted, accepted and understood by their clinicians. Achieving this goal requires common decision-making.

Clinicians can never ensure that patients meet all treatment goals. However, patients reporting positive life changes (such as stable housing and improved relationships) may be satisfied with the current dose. For patients who do not increase the dose to 32 mg, clinicians may consider using different treatment plans, such as 30-day buprenorphine injections, which can provide higher doses or transition to methadone, another highly effective FDA-approved drug for opioid use disorders.

FDA Guideline Changes

In August 2022, the team of addiction doctors tried to move the FDA to change the dosage guidelines for buprenorphine. They submitted a petition asking for modern guidelines based on patient responses to buprenorphine (including relieving symptoms and reducing illicit drug use) rather than a fixed “targeted” dose. They asked to remove language that falsely deny evidence showed that patients benefited from doses above 24 mg.

The FDA listened. In December 2023, it held a public meeting with leading addiction clinicians, researchers and policy makers to review evidence on buprenorphine doses. The group reached an overwhelming consensus that extensive research was conducted to show that doses were at doses above 24 mg. Furthermore, they doubt whether the administration conclusions of the guidelines were drawn before fentanyl penetrated into today's drug supply.

Then, the FDA responded. In December 2024, it announced a new buprenorphine recommendation that would not mention the target dose and would not deny the evidence of the 24 mg above welfare. Only time will determine whether and when the FDA's new guidelines will meaningfully change prescription patterns, insurance and pharmacy restrictions, and state laws.

To maintain a national trend to reduce excessive death, the optimal use of each effective treatment is crucial. However, the Trump administration’s proposal to cut Medicaid (which covers half of all buprenorphine prescriptions) put Access at serious threat. Most untreated addictions will be blocked from fully accessing treatment, not to mention effective doses or behavioral health, social work and recovery support services required with the best results. Research shows that buprenorphine prescriptions have dropped dramatically after Medicaid coverage limits in 2023.

Opioid use disorder is treatable. Buprenorphine works well when given at the right dose and can save lives. Inadequate doses can directly harm patients who are just trying to survive and improve their lives.