Can Suboxone (buprenorphine) be initiated in a patient who last used heroin 3 days ago?

From the Guidelines

Starting Suboxone on a patient who used heroin 3 days ago is generally safe, but the patient must be in moderate withdrawal first to avoid precipitated withdrawal. The patient should wait until they score at least 8-10 on the Clinical Opiate Withdrawal Scale (COWS), which typically occurs 12-24 hours after last heroin use 1. Since it has been 3 days since the patient's last use, they are likely already in sufficient withdrawal to start Suboxone.

Key Considerations

• The typical induction protocol begins with 2-4mg of Suboxone, with additional 2-4mg doses every 1-2 hours as needed for withdrawal symptoms, up to 8-16mg on day one 1.
• The dose can be adjusted in subsequent days based on the patient's response, with maintenance doses typically ranging from 8-24mg daily 1.
• Before starting, the provider should confirm withdrawal symptoms are present, verify the patient hasn't used long-acting opioids recently, and ensure there are no contraindications.
• Suboxone works by partially activating opioid receptors (through buprenorphine) while the naloxone component helps prevent misuse, making it effective for opioid use disorder treatment while reducing the risk of overdose.

Important Factors to Consider

• Buprenorphine should be administered only to patients in active opioid withdrawal as confirmed by history and physical examination 1.
• Particular care is required when transitioning from methadone to buprenorphine because of the risk of severe and prolonged precipitated withdrawal 1.
• The presence of at least mild withdrawal symptoms should be verified by the administration of a validated opioid withdrawal scale 1.

From the Research

Initiating Suboxone Treatment

• The decision to start Suboxone on a patient who used heroin 3 days ago depends on the patient's level of opioid withdrawal and physical dependence on opioids 2.
• The Clinical Opiate Withdrawal Scale (COWS) is a useful tool for assessing the severity of opioid withdrawal and determining the patient's readiness for Suboxone induction 2, 3.
• Buprenorphine, the active ingredient in Suboxone, can precipitate opioid withdrawal in patients with a high level of opioid dependence who are not experiencing opioid withdrawal 2.
• It is essential to evaluate the patient's withdrawal symptoms and level of physical dependence before initiating Suboxone treatment to avoid precipitated withdrawal 3, 4.

Considerations for Buprenorphine Induction

• Buprenorphine is an effective treatment for opioid addiction disease, but its induction can trigger severe precipitated withdrawal in opioid-dependent patients 3.
• The American Society of Addiction Medicine recommends using a validated tool, such as the COWS, to assess a patient's level of withdrawal before initiating buprenorphine treatment 3.
• Nurses and healthcare providers should be educated on the use of the COWS to improve care for adult patients undergoing buprenorphine induction 3.
• The treatment of opioid withdrawal is an important area of clinical concern, and current standards of care include treatment with μ-opioid receptor agonists, partial agonists, and α2-adrenergic receptor agonists 4.

Assessment and Monitoring

• Assessing the patient's level of withdrawal using a validated tool, such as the COWS, is crucial for successful transition from other opioids to buprenorphine 2, 3.
• Monitoring withdrawal symptoms and adjusting the treatment plan as needed is essential for patient safety and effective treatment outcomes 3, 4.
• Healthcare providers should be aware of the potential for precipitated withdrawal and take steps to minimize its occurrence, such as gradual tapering of opioids or using medications to alleviate withdrawal symptoms 4.