Unintentional use of fentanyl attributed to surreptitious cannabis adulteration

Objective: This case addresses the issue of surreptitious adulteration of cannabis. Many with opioid and substance use disorders use cannabis while receiving office-based opioid treatment (OBOT), making it valuable to understand the rationale for its use. Further study of the effects that cannabis use has on OBOT success or failure is necessary. Case summary: A 50-year-old man receiving OBOT continually tested positive in urine drug screenings (UDSs) for fentanyl, while abstaining from all opiates, but he endorsed smoking cannabis 2-3 times weekly as a self-reported headache reliever and a sleep aid. After changing the source from which he bought cannabis, his UDS became negative for fentanyl. He was maintained on a stable dose of buprenorphine with a consistent UDS after this intervention and was able to make many positive lifestyle changes as a result (i.e., maintaining a relationship with his girlfriend, continuing attendance at support groups, and pursuing employment opportunities). Practice implications: The consequences of cannabis use on OBOT success are highly variable and dependent on many factors. Although the concern regarding adulteration of cannabis exists, there is no systematic monitoring or reliable data on its frequency or the magnitude of its effect, which generates a demand for further research and exploration. Depending on state-specific regulations, patients may be able to obtain cannabis from reliable, regulated (nonadulterated) sources. However, providers must thoroughly consider the barriers to patients obtaining medicinal or legalized cannabis.