Opioid Use Disorder in the Fentanyl Era: What Every Clinician Should Know

Opioid use disorder has changed in the fentanyl era. Learn practical clinical pearls on MOUD, buprenorphine initiation, naloxone, COWS, harm reduction, screening, and compassionate OUD treatment.

You do not have to practice addiction medicine to encounter opioid use disorder.

It shows up in primary care, psychiatry, emergency medicine, hospital medicine, pain management, women’s health, and behavioral health. And today, the opioid landscape looks very different from the one many clinicians learned about during training.

Fentanyl has changed the drug supply. Polysubstance exposure is common. Buprenorphine access has expanded. Harm reduction has become an increasingly important part of keeping patients alive long enough to recover.

That is why opioid use disorder, or OUD, is something every clinician should understand—even if addiction medicine is not your specialty.

In this Mini Mindset episode of PA Mindset Matters, we break down what has changed and what clinicians can actually do differently in practice.

The Fentanyl Era Changed the Clinical Landscape

For years, U.S. overdose deaths climbed to devastating levels, with illegally manufactured fentanyl becoming a major driver. There is now encouraging news: CDC provisional data estimated approximately 69,973 overdose deaths in 2025, nearly 14% fewer than in 2024. Opioid-involved deaths also declined.

That progress matters. But it does not mean the problem has disappeared.

Fentanyl remains deeply embedded in the illicit drug supply, including counterfeit pills and substances such as heroin, cocaine, and methamphetamine. Patients may therefore be exposed without realizing it.

For clinicians, the takeaway is straightforward:

Screen broadly.

Do not ask only about “opioids.” Ask about counterfeit pills, stimulants, benzodiazepines, alcohol, sleep medications, and other sedating substances.

The respiratory system does not care whether substances came from separate prescriptions, separate clinicians, or different categories on our intake form. Combining opioids with benzodiazepines, alcohol, and other central nervous system depressants can substantially increase overdose risk.

Detox Is Not the Same as Treatment

One of the most important misconceptions we discuss in this episode is:

“I just need to detox.”

Withdrawal management can be an important first step, but getting opioids out of the body does not treat the underlying opioid use disorder.

In fact, stopping there can increase danger.

After a period of abstinence, opioid tolerance decreases. If someone later returns to a previously tolerated dose—or encounters fentanyl in the illicit drug supply—the risk of overdose can be substantial.

Current CDC guidance specifically states that detoxification without medication for opioid use disorder is not recommended as treatment for OUD because of the increased risks of return to use, overdose, and overdose death.

The clinical pearl:

Getting someone through withdrawal is not the finish line.

The question should always become: What happens next?

Medication for Opioid Use Disorder Is Treatment

Another persistent stigma is the idea that using an opioid medication to treat opioid addiction simply “replaces one drug with another.”

That confuses physiological dependence with addiction.

The goal of treatment is not simply to make sure every opioid receptor is empty. The goal is to interrupt the destructive cycle of intoxication, withdrawal, craving, compulsive use, and escalating risk—and help a patient regain stability and function.

Three FDA-approved medications are central to OUD treatment:

Buprenorphine

A partial mu-opioid receptor agonist that can reduce cravings and withdrawal while providing greater receptor stability.

Methadone

A full opioid agonist used for OUD treatment through federally regulated opioid treatment programs.

Naltrexone

An opioid antagonist that blocks opioid effects but requires the patient to first complete opioid withdrawal before initiation.

Medication treatment for OUD is associated with reduced opioid use, and buprenorphine and methadone are associated with lower overdose and overall mortality.

Importantly, the federal X-waiver requirement was eliminated. Practitioners with appropriate DEA registration and prescribing authority may prescribe buprenorphine for OUD without obtaining the former DATA waiver, subject to applicable state law and other federal requirements.

That means more clinicians can become part of the treatment pathway.

Buprenorphine and Fentanyl: Treat the Patient, Not Just the Clock

One of the biggest sources of clinician anxiety is precipitated withdrawal.

Buprenorphine has very high affinity for the mu-opioid receptor. If it is introduced while a full opioid agonist is still exerting substantial effects, it can displace that opioid and produce an abrupt decrease in opioid activity—triggering a rapid worsening of withdrawal.

Historically, clinicians often relied heavily on the number of hours since the patient's last opioid use.

Fentanyl has made that approach less reliable.

Current guidance emphasizes assessing objective withdrawal, not simply watching the clock. The Clinical Opiate Withdrawal Scale, or COWS, can help evaluate signs such as pupil dilation, sweating, restlessness, yawning, rhinorrhea, tearing, tremor, gooseflesh, and gastrointestinal symptoms.

Different patients and clinical settings may call for different initiation strategies, including traditional induction, higher-dose approaches, or low-dose buprenorphine initiation.

The larger message is more important than memorizing one number:

Treat the person in front of you and assess what their body is telling you—not just how many hours have passed.

Fear of precipitated withdrawal should make us more thoughtful about buprenorphine initiation, not more afraid to treat OUD.

Naloxone Is an Opportunity for Recovery

Harm reduction can still trigger uncomfortable questions:

“If we give people naloxone, are we making opioid use safer?”

The better question is: Do we want people to survive an overdose?

Naloxone can rapidly reverse an opioid overdose, including one involving fentanyl.

Think of naloxone like a fire extinguisher.

Owning a fire extinguisher does not encourage someone to start a fire. It provides a lifesaving tool when something goes wrong.

The same principle applies here.

Clinicians should think proactively about naloxone for people with OUD and for patients with increased overdose risk, including those receiving opioids with benzodiazepines or higher-risk opioid regimens. CDC guidance recommends offering naloxone to patients at increased overdose risk and providing overdose-prevention education to patients and household members when appropriate.

Harm reduction is healthcare.

Keeping someone alive provides another opportunity for treatment, recovery, relationships, purpose, and change.

Use PDMPs and Drug Testing as Clinical Information, Not Punishment

Prescription drug monitoring programs and toxicology testing can provide important information—but mindset matters.

A PDMP should not simply be a regulatory checkbox.

It can help identify multiple prescribers, overlapping controlled substances, or medication combinations that increase risk.

Likewise, an unexpected urine drug test should not automatically translate into:

“You broke the rules. You’re discharged.”

CDC guidance recommends that clinicians explain that toxicology results are intended to improve safety rather than be used punitively or as an automatic reason for dismissal from care.

Unexpected results are information.

Maybe treatment is not adequate.

Maybe another substance has entered the picture.

Maybe the patient is destabilizing.

Maybe there is something happening in their environment that we have not asked about.

Remain curious.

You May Only Have Three Minutes—and Three Minutes Matter

Clinicians often hear “motivational interviewing” and imagine a 30-minute counseling session.

Most of us do not have that kind of time.

But we may have three minutes.

A conversation can begin with:

“Would it be okay if we spent a couple of minutes talking about your opioid use?”

Then listen.

Ask about sleep. Anxiety. Relationships. Work. Housing. Recovery supports. Transportation. What matters to them. What has changed.

Instead of immediately telling someone why they should change, help them identify their own reasons.

If a patient rates their confidence to change as a four out of ten, instead of asking why it is not an eight, consider asking:

“Why a four and not a two?”

Now the patient begins telling you why change might be possible.

That is motivational interviewing in everyday clinical practice.

And as Jessica notes in the episode, it is called clinical practice—not clinical perfection. The work also requires clinician self-awareness: recognizing when fatigue, frustration, or our own reflex to “fix” the problem is getting in the way of listening.

Five OUD Clinical Pearls to Take Into Practice

1. Opioid use disorder is a chronic, treatable medical condition. Evidence-based medications are part of standard care.

2. Detox is not treatment. Withdrawal management should connect to an ongoing OUD treatment plan.

3. Fentanyl has changed buprenorphine initiation. Assess objective withdrawal and the individual patient rather than relying solely on elapsed time.

4. Treat PDMP and toxicology results as clinical data. Unexpected information should lead to curiosity, safety assessment, and conversation—not reflexive punishment.

5. Harm reduction is healthcare. Think proactively about naloxone and overdose prevention.

Perhaps most importantly, you do not have to solve everything in one visit.

Ask one open-ended question.

Start one conversation.

Offer one evidence-based treatment option.

Connect one patient to the next appropriate level of care.

Sometimes that is how recovery begins.

Listen to the Full Mini Mindset Episode

In this episode of PA Mindset Matters, psychiatric PAs Mercedes Dodge and Jessica Spissinger take a practical clinician-to-clinician look at opioid use disorder in the fentanyl era—from polysubstance risk and medication treatment to buprenorphine initiation, COWS, naloxone, harm reduction, motivational interviewing, and compassionate recovery-focused care.

🎧 Listen to the full episode of PA Mindset Matters on Apple Podcasts, Spotify, Podbean, and YouTube.

And follow PA Mindset Matters for more Mini Mindset episodes translating psychiatry, addiction medicine, and behavioral health into practical tools clinicians can use in real-world care.

Compassionate Care in Addiction Medicine: A Conversation with Karen Haessler PA-C

Insights from Karen Haessler, PA-C, on reducing stigma, navigating substance use disorders, and building meaningful connections with patients.

Addiction medicine isn't just for addiction specialists. Whether working in emergency medicine, primary care, psychiatry, surgery, or obstetrics, PAs regularly encounter patients affected by substance use disorders. Yet stigma, limited training, and uncertainty about treatment can create barriers to effective care.

In a recent episode of PA Mindset Matters, hosts Jessica Spissinger and Mercedes Dodge spoke with Karen Haessler, PA-C, an addiction medicine PA whose career spans 25 years in paramedicine, emergency medicine, and hospital-based addiction treatment.

From building an addiction consult service to navigating complex withdrawal presentations, Karen shares practical lessons that every PA can incorporate into clinical practice.

Building Addiction Care Into Everyday Medicine

Karen's journey into addiction medicine began long before she became a PA. After 25 years as a paramedic and subsequent experience in emergency medicine, she helped develop a grant-funded, hospital-wide addiction consult program.

The service supports patients across emergency departments, inpatient units, orthopedic surgery, and obstetrics and gynecology.

This integrated approach recognizes a fundamental reality: substance use disorders don't exist in isolation from other medical conditions.

A patient hospitalized for an infection, fracture, or pregnancy-related complication may also need treatment for opioid use disorder or alcohol withdrawal. Addressing these needs during hospitalization creates opportunities to initiate treatment, prevent complications, and connect patients with ongoing care.

Language Is Harm Reduction

One of the most important themes of the conversation is that how we speak to patients matters.

Stigmatizing language can reinforce shame, discourage disclosure, and undermine trust. Simple changes in terminology can help create a more supportive clinical environment.

Consider these substitutions:

• Instead of "addict," use "person with a substance use disorder."

• Instead of "clean" or "dirty" urine, use "negative" or "positive" toxicology results.

• Instead of "drug abuse," use "substance use" or "unhealthy substance use."

• Instead of "noncompliant," describe the specific barriers affecting treatment participation.

Language alone won't eliminate stigma, but it can change the tone of a clinical encounter.

For patients who have experienced judgment or discrimination in healthcare settings, respectful communication may be the first step toward rebuilding trust.

Opioid Use Disorder: Treatment Shouldn't Have to Wait

Hospitalization provides an important opportunity to initiate medications for opioid use disorder (MOUD), including buprenorphine and methadone.

These evidence-based treatments reduce opioid-related mortality and support long-term recovery.

Karen discusses several clinical situations that require thoughtful management.

Buprenorphine Around Surgery

Patients receiving buprenorphine may require surgery or treatment for acute pain. Historically, clinicians often discontinued buprenorphine before procedures because of concerns about pain control.

Current guidance generally supports continuing buprenorphine through the perioperative period, with individualized adjustments when necessary.

Multimodal analgesia, coordination with anesthesia and addiction specialists, and appropriate use of additional analgesics can help manage pain while minimizing the risks associated with treatment interruption.

Low-Dose Buprenorphine Initiation

For patients exposed to fentanyl or other highly potent synthetic opioids, traditional buprenorphine initiation can be challenging because of concerns about precipitated withdrawal.

Low-dose initiation strategies, sometimes called microinduction, allow buprenorphine to be introduced gradually while a full opioid agonist is still present.

These approaches require appropriate clinical protocols and monitoring but can offer another pathway into treatment.

Addiction Treatment During Pregnancy

Karen also describes the importance of integrated addiction treatment during pregnancy, including methadone initiation and programs such as Moms Do Care.

Pregnant patients with opioid use disorder may face significant stigma and fear of judgment or legal consequences.

Evidence-based treatment, coordinated prenatal care, and compassionate communication are essential to supporting both maternal and infant health.

Alcohol Withdrawal: Recognize Risk Early

Alcohol withdrawal is another common and potentially life-threatening condition encountered across healthcare settings.

Karen highlights the importance of early screening, identifying patients at risk for complicated withdrawal, and following established treatment protocols.

Clinical pearls for PAs:

1. Assess withdrawal risk before symptoms become severe. A history of withdrawal seizures or delirium tremens is particularly important.

2. Recognize that withdrawal can progress rapidly. Seizures and delirium tremens may occur even when initial symptoms appear relatively mild.

3. Use structured assessment appropriately. Tools such as CIWA-Ar can support symptom monitoring in suitable patients, but they have limitations in patients who cannot reliably communicate.

4. Don't overlook thiamine. Patients with chronic heavy alcohol use or malnutrition may be at risk for Wernicke encephalopathy, a potentially serious neurologic emergency.

5. Know when to escalate care. Severe autonomic instability, seizures, delirium, and significant medical comorbidities warrant higher levels of monitoring and treatment.

Standardized protocols help clinicians recognize deterioration and deliver timely, evidence-based care.

Emerging Substances: Kratom, Fentanyl, and Beyond

The substance use landscape continues to evolve, requiring clinicians to remain curious and informed.

Karen discusses emerging concerns involving fentanyl adulterants, including xylazine and medetomidine, as well as kratom.

Kratom Is Not Necessarily Benign

Kratom is often marketed as a natural product for pain, mood, or opioid withdrawal. However, its active alkaloids interact with opioid receptors, and regular use can lead to physical dependence and withdrawal.

Symptoms may resemble opioid withdrawal, including anxiety, gastrointestinal distress, restlessness, and insomnia.

Karen discusses the use of buprenorphine for kratom withdrawal, an emerging off-label treatment approach supported primarily by limited clinical evidence.

A key takeaway is to ask specifically about kratom and other nonprescription substances rather than assuming patients will include them when discussing drug use.

Recognizing New Adulterants

Xylazine and medetomidine are non-opioid sedating agents that may appear in the illicit opioid supply.

Their presence can complicate intoxication and withdrawal presentations. Naloxone remains essential when opioid exposure is suspected, although it does not reverse the direct effects of these non-opioid substances.

Supportive care, monitoring, and awareness of local drug supply trends are increasingly important.

The Therapeutic Alliance Is a Clinical Intervention

Beyond medications and protocols, one of the most meaningful themes of the conversation is the importance of human connection.

Patients with substance use disorders may have experienced repeated rejection, judgment, or fragmented healthcare. Clinicians have an opportunity to offer something different.

That begins with listening without assumptions, recognizing ambivalence, respecting patient autonomy, and understanding that recovery rarely follows a linear path.

It also requires self-reflection.

What assumptions do we bring into the room? How might frustration, burnout, or unconscious bias influence our interactions?

Compassionate care does not mean abandoning clinical boundaries or ignoring risk. It means approaching patients with dignity while providing evidence-based treatment.

Building Your Addiction Medicine Skills

PAs do not need to specialize in addiction medicine to make a meaningful difference.

Karen highlights several resources for clinicians interested in expanding their knowledge:

• Providers Clinical Support System (PCSS): Education, mentorship, and clinical resources related to substance use disorders.

• American Society of Addiction Medicine (ASAM): Clinical guidelines, education, and professional development.

• Boston Medical Center Grayken Center for Addiction: Addiction medicine training and educational resources.

Even small improvements in screening, communication, withdrawal recognition, and treatment initiation can improve patient care.

The Bottom Line: Every PA Has a Role in Addiction Care

Addiction medicine is not defined solely by prescribing buprenorphine, managing withdrawal, or working on a specialty consult service.

It is also about recognizing opportunities to intervene, reducing barriers to treatment, and creating clinical environments where patients feel safe seeking help.

Karen Haessler's experiences remind us that meaningful addiction care requires both clinical knowledge and human connection.

We may not be able to change a patient's entire journey in one encounter, but we can change how they experience healthcare in that moment.

And sometimes, that is where recovery begins.

Listen to the Episode

PA Mindset Matters: Compassionate Care in Addiction Medicine — A Conversation with Karen Haessler

Join Jessica Spissinger and Mercedes Dodge for a conversation about addiction medicine, harm reduction, emerging substance use trends, and practical strategies for providing compassionate, evidence-based care.

Addressing stigma, unlocking skills.

Alcohol Use Disorder: From Screening to Treatment—What Every PA Should Know

PA Mindset Matters | Mini Mindset

Alcohol is everywhere. From celebrations and social gatherings to unwinding after a long day, drinking is deeply embedded in our culture. But when does alcohol use become a clinical concern, and how can healthcare providers recognize when a patient needs help?

Alcohol use disorder (AUD) is one of the most prevalent substance use disorders worldwide, contributing to significant medical, psychiatric, and social consequences. Yet it frequently goes unrecognized in clinical practice.

In this Mini Mindset episode of PA Mindset Matters, we explore the essentials of identifying, assessing, and treating AUD, with practical insights that PAs can apply across specialties.

Understanding Alcohol Use Disorder

AUD is not simply a matter of drinking too much or lacking willpower. It is a complex condition influenced by genetics, environment, personality traits, and cognitive functioning.

Genetics may account for approximately half of an individual's vulnerability to AUD. Environmental influences, including family dynamics, early exposure, and peer relationships, also contribute. Co-occurring psychiatric conditions, particularly depression, bipolar disorder, and other substance use disorders, can further complicate the clinical picture.

Clinical Pearl: AUD is a medical condition, not a moral failing. Approaching patients with curiosity rather than judgment creates opportunities for meaningful conversations about alcohol use.

Screening: Starting the Conversation

One of the most valuable tools PAs have is the ability to identify unhealthy alcohol use before serious complications develop.

Several validated screening instruments can help:

• AUDIT/AUDIT-C: Identifies unhealthy alcohol consumption and potential AUD.

• CAGE: Four brief questions exploring attempts to cut down, criticism, guilt, and morning drinking.

• SASQ: A single-question approach to identifying unhealthy alcohol use.

• T-ACE: A screening tool developed for identifying risky drinking during pregnancy.

Screening is only the beginning. A positive result should lead to further assessment, a nonjudgmental conversation, and an individualized plan.

Clinical Pearl: Asking about alcohol use should be as routine as asking about tobacco use, medications, or sleep.

Recognizing Intoxication and Withdrawal

Alcohol intoxication can present with slurred speech, impaired coordination, unsteady gait, poor judgment, and changes in attention or memory. Severe intoxication can progress to respiratory depression, stupor, or coma.

Withdrawal presents a different challenge and can become life-threatening.

Symptoms may begin within hours after a significant reduction or cessation of prolonged heavy alcohol use. Early symptoms include tremors, anxiety, nausea, sweating, and insomnia. More severe withdrawal can involve hallucinations, seizures, and delirium tremens.

Withdrawal severity depends on multiple factors, including prior withdrawal history, drinking patterns, and co-occurring medical conditions.

Clinical Pearl: A history of withdrawal seizures or delirium tremens is an important warning sign. Patients at risk for complicated withdrawal require prompt assessment and an appropriate level of medical monitoring.

Complications Beyond the Liver

Although liver disease is often associated with chronic alcohol use, AUD affects nearly every organ system.

Neurologic complications include peripheral neuropathy, cerebellar dysfunction, and thiamine-deficiency syndromes.

Two particularly important conditions are:

Wernicke Encephalopathy: An acute neurologic emergency associated with thiamine deficiency. Classic findings include confusion, ataxia, and ocular abnormalities, although not every patient presents with all three.

Korsakoff Syndrome: A chronic amnestic disorder characterized by profound memory impairment and, sometimes, confabulation.

Chronic alcohol use also contributes to cardiovascular disease, pancreatitis, gastrointestinal complications, malnutrition, and reproductive health concerns.

Alcohol exposure during pregnancy can result in fetal alcohol spectrum disorders (FASD), affecting growth, neurodevelopment, and lifelong functioning. No safe level of alcohol consumption during pregnancy has been established.

Clinical Pearl: Think beyond intoxication. A patient presenting with confusion, gait abnormalities, or unexplained cognitive changes may have an alcohol-related neurologic complication.

Managing Withdrawal: CIWA-Ar and Thiamine

For patients experiencing alcohol withdrawal, structured assessment helps guide management.

The Clinical Institute Withdrawal Assessment for Alcohol, Revised (CIWA-Ar) evaluates symptoms including tremors, sweating, agitation, nausea, anxiety, sensory disturbances, and orientation.

When appropriate, CIWA-Ar can support symptom-triggered treatment protocols, often involving benzodiazepines. However, it should complement clinical judgment rather than replace assessment of withdrawal risk, medical stability, and monitoring needs.

Thiamine supplementation is another essential consideration, particularly for patients with chronic heavy alcohol use, malnutrition, or suspected Wernicke encephalopathy. In patients at risk, thiamine should be administered promptly, ideally before glucose when feasible, without delaying emergency treatment of hypoglycemia.

Clinical Pearl: Withdrawal management is about more than controlling symptoms. Preventing seizures, delirium, and neurologic injury is equally important.

SBIRT: A Practical Framework for Every PA

Not every patient with unhealthy alcohol use needs inpatient treatment, but every patient deserves an opportunity for intervention.

SBIRT provides a practical approach:

• Screening: Identify unhealthy alcohol use using validated tools.

• Brief Intervention: Engage patients in a motivational, nonjudgmental conversation about their drinking and readiness for change.

• Referral to Treatment: Connect patients with medication, counseling, and additional recovery resources when indicated.

Even a brief conversation can help patients recognize risks and consider change.

Medications for Alcohol Use Disorder

AUD treatment extends well beyond detoxification. Long-term management may include medications, psychotherapy, behavioral interventions, and recovery support.

Three FDA-approved medications are commonly considered:

Naltrexone: Reduces the rewarding effects of alcohol and can help decrease heavy drinking. Available in oral and monthly injectable formulations, it requires careful consideration of opioid use and liver function.

Acamprosate: Helps support abstinence after alcohol cessation and is particularly useful for patients working toward sustained recovery. Renal function is an important prescribing consideration.

Disulfiram: Produces an unpleasant physical reaction when alcohol is consumed and may be appropriate for carefully selected, motivated patients.

Other medications, including topiramate and emerging treatments such as GLP-1 receptor agonists, are being explored for their potential roles in AUD treatment. These approaches differ in the strength of available evidence and are not FDA-approved for AUD.

Clinical Pearl: Treatment should begin with the patient's goals. Reducing heavy drinking, achieving abstinence, and maintaining recovery may require different strategies, but all benefit from ongoing, patient-centered care.

The Takeaway: Every PA Has a Role

Alcohol use disorder is not confined to addiction medicine or psychiatry. Patients experiencing AUD present in primary care, emergency departments, surgical services, women's health, and nearly every other clinical setting.

Recognizing unhealthy alcohol use, identifying dangerous withdrawal, understanding treatment options, and approaching patients without stigma are skills every PA should develop.

We don't have to solve every aspect of a patient's alcohol use in one encounter. Sometimes the most meaningful intervention begins with a simple question, a compassionate response, and a willingness to keep the conversation going.

All PAs are Psych PAs!

Listen to Mini Mindset: Alcohol Use Disorder

Join Jessica Spissinger and Mercedes Dodge on PA Mindset Matters for a focused discussion of AUD screening, withdrawal, complications, and treatment basics.

Big insights, bite-sized.

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