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Heroin Addiction and Related Clinical Problems: 2025, 27, 24

Management of Patients in an Unstable Phase of Opioid Use Disorder: Challenges, Goals, and Emerging Evidence on Long-Acting Buprenorphine

Catriona Matheson, Michael Soyka, Bernadette Hard, Georges Brousse, Susanna Meyner, Carola Seibold, and Marta Torrens

Digital Object Identifier:
https://doi.org/10.62401/2531-4122-2025-24

Summary: Patients with opioid use disorder (OUD) exhibit substantial variation in disease complexity and stability, requiring individualised treatment approaches. Those in an "unstable phase”, typically associated with low treatment retention or significant opioid use, face higher risks. They often require daily supervised medication due to their risk profile, yet managing this can be challenging. The absence of consensus on their identification and treatment is concerning, especially given the high-potency synthetic opioid crisis. Here, we describe challenges faced in identifying and treating these patients, the role of treatment, and treatment goals. We call for increased recognition of and research into these patients’ needs. Various factors can indicate an unstable phase in OUD, including low adherence, polydrug use, unstable housing, and somatic or psychiatric comorbidities. In such phases, challenges posed by daily methadone or oral buprenorphine treatment, such as requirements for daily clinic attendance, specific timing and dosing of medication, and pressure to divert medication, may be more significant. Furthermore, different treatment objectives may be needed in unstable versus stable phases. Long-acting injectable buprenorphine presents an alternative that could potentially address these challenges and patient needs. Given current knowledge gaps, more research is needed on treatment options and outcomes beyond abstinence in unstable phases, such as reduction of illicit drug use and harm reduction including reduced risk of death. Evidence and clinician opinion suggest long-acting injectable buprenorphine can be effective in unstable phases, though it must be balanced with risks and patient circumstances. Better identification of and tailored treatment strategies for this vulnerable population are essential.

Keywords: Opioid-Related Disorders; Opioid Dependence; Opioid Use Disorder; Opioid Maintenance Treatment; Retention