From the Guidelines
Starting Suboxone in someone who used heroin 3 days ago is generally safe and appropriate, as long as the patient is in a state of mild to moderate withdrawal, which can be confirmed using a validated opioid withdrawal scale, such as the Clinical Opiate Withdrawal Scale (COWS) 1. The patient should be assessed for withdrawal symptoms, and if they are experiencing at least mild withdrawal, they can receive Suboxone. The standard protocol involves starting with a low dose (2-4mg) and observing for 1-2 hours before giving additional medication if withdrawal symptoms persist, up to 8-16mg on the first day, as recommended by recent guidelines 1. This cautious approach prevents precipitated withdrawal, which occurs when Suboxone displaces full opioids from receptors too quickly. Precipitated withdrawal is less of a concern after 3 days since most heroin should be cleared from the body. Some key points to consider when starting Suboxone include:
- Assessing withdrawal symptoms using a validated scale, such as COWS 1
- Starting with a low dose (2-4mg) and titrating up as needed 1
- Monitoring for side effects, including headache, nausea, constipation, and insomnia during the induction phase
- Ensuring the patient is in a state of mild to moderate withdrawal before starting Suboxone, which typically occurs 12-24 hours after last heroin use 1. It is also important to note that the dosage of Suboxone may vary, and a daily dosage of 16 mg is sufficient to suppress illicit opioid use in most patients with OUD, but sufficient dosages can range from 4-24 mg daily 1.
From the FDA Drug Label
Patients Dependent on Heroin or Other Short-acting Opioid Products At treatment initiation, the first dose of Buprenorphine Sublingual Tablets should be administered only when objective and clear signs of moderate opioid withdrawal appear, and not less than 4 hours after the patient last used an opioid
The patient used heroin 3 days ago, which means they are likely to be experiencing opioid withdrawal. Buprenorphine Sublingual Tablets can be started when objective and clear signs of moderate opioid withdrawal appear, and it has been at least 4 hours since the last opioid use. Since it has been 3 days, it is likely that the patient is experiencing withdrawal and the first dose can be administered. 2
From the Research
Initiating Suboxone in Heroin Users
- The decision to start Suboxone in someone who used heroin 3 days ago depends on the individual's level of opioid withdrawal and physical dependence on opioids 3, 4.
- The Clinical Opiate Withdrawal Scale (COWS) is a useful tool to quantify the severity of opiate withdrawal and assess a patient's level of physical dependence on opioids 5, 3, 4, 6.
- Buprenorphine, the active ingredient in Suboxone, can precipitate opiate withdrawal in patients with a high level of opioid dependence who are not experiencing opioid withdrawal 3, 4.
- It is essential to evaluate the patient's level of withdrawal using a validated tool like COWS before initiating Suboxone to ensure a safe and successful transition from other opioids to buprenorphine 4, 6.
- Studies have shown that educating nurses on the use of COWS can improve care of adult patients undergoing buprenorphine induction and lead to better withdrawal management 4, 6.
Considerations for Initiating Suboxone
- The patient's recent heroin use (3 days ago) may indicate a high level of opioid dependence, and initiating Suboxone without proper assessment and management of withdrawal symptoms may lead to precipitated withdrawal 3, 4.
- A thorough evaluation of the patient's medical history, current symptoms, and level of physical dependence on opioids is necessary before starting Suboxone 7, 3, 4.
- The use of COWS can help healthcare providers make informed decisions about the timing and safety of initiating Suboxone in patients with opioid use disorder 5, 3, 4, 6.