Skip The Strip: Talking Direct to Inject for OUD With Dr. Reb Close

Getting someone from fentanyl to buprenorphine can be one of the hardest transitions in addiction medicine, and not because people “don’t want it.” The pharmacology is unforgiving: start too soon and precipitated withdrawal can hit fast, loud, and memorable enough that patients never want to try bupe again. We sit down with Dr. Reb Close to talk through a newer approach that’s gaining traction, Direct To Inject (DTI), and what it looks like when you actually do it in the real world.  We explain why fentanyl’s long tail changes everything, then map the options we offer patients: macrodosing, microdosing with a cross taper, microdosing without a cross taper, and DTI. You’ll hear how DTI uses a weekly long-acting injectable buprenorphine dose that comes on over about 24 hours, effectively creating a built-in “microdose ramp” while the patient navigates that first day. We also get specific about comfort meds, safety counselling, and how we handle the common moment where someone feels terrible but hasn’t taken any of the meds meant to help.  From street-based care to clinic workflows, we share what withdrawal severity looks like across patients, when DTI is not a good option, how we think about methadone switches, and why we often push toward high-dose monthly injectable buprenorphine for a longer protective tail. If you care about practical fentanyl-era buprenorphine induction, retention, and overdose prevention, this one is for you. Subscribe, share with a colleague, and leave a review so more people can find the show.To contact Dr. Grover: ammadeeasy@fastmail.com