Importance: The emergence of fentanyl and other high-potency synthetic opioids (HPSOs) has not only been underlying overdose deaths, but has complicated initiation of methadone and buprenorphine for opioid use disorder (OUD) treatment, including in the hospital. In response, clinicians with addiction expertise have developed novel initiation practices, yet no studies have characterized initiation practices nationally.

Question: How commonly are hospital-based addiction clinicians in the US using novel methadone and buprenorphine initiation practices to address challenges brought by fentanyl and high-potency synthetic opioid use?

Findings: In this national, cross-sectional survey study of 58 addiction fellowship–associated hospital consult service directors, practices including rapid methadone initiation, use of full-agonist opioids for opioid withdrawal, and use of low- and high-dose buprenorphine initiation were widespread.

Meaning: These findings suggest that among hospital-based academic addiction consult directors, methadone and buprenorphine initiation in the hospital setting is adapting to a shifting opioid supply, often outpacing advances in research and clinical guidelines.