From the Guidelines
No, suboxone should not be started during acute opioid withdrawal, as it can precipitate severe withdrawal symptoms. Instead, it should be initiated only when moderate withdrawal symptoms are present, typically 12-24 hours after the last short-acting opioid use or 36-48 hours after long-acting opioid use, as recommended by experts 1. Starting suboxone too early can displace full agonists from receptors, leading to severe withdrawal symptoms, because buprenorphine, a component of suboxone, is a partial opioid agonist. Clinicians should use the Clinical Opiate Withdrawal Scale (COWS) to assess withdrawal severity, with a score indicating appropriate timing for suboxone initiation, as the presence of at least mild withdrawal symptoms should be verified by the administration of a validated opioid withdrawal scale 1. The typical starting dose is 2-4mg sublingually, with additional doses as needed up to 8-16mg on the first day, and patients should be monitored for at least 1-2 hours after the initial dose to ensure they don't experience worsening symptoms. Key considerations in the management of opioid withdrawal include the use of α2-adrenergic agonists, such as clonidine or lofexidine, as well as antiemetics, atypical antipsychotics, and other medications targeting the withdrawal symptoms, as outlined in clinical policies 1. However, the most effective approach to alleviating withdrawal symptoms and initiating medication for addiction treatment (MAT) for OUD is the appropriate use of buprenorphine or methadone, with the initiation of buprenorphine requiring that patients must be experiencing opioid withdrawal, and the presence of at least mild withdrawal symptoms verified by a validated opioid withdrawal scale 1.
From the FDA Drug Label
2.3 Induction Prior to induction, consideration should be given to the type of opioid dependence (i.e., long- or short-acting opioid products), the time since last opioid use, and the degree or level of opioid dependence 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
Buprenorphine Sublingual Tablets, which is the suboxone component without naloxone, should be started during acute opioid withdrawal, but only when objective and clear signs of moderate opioid withdrawal appear.
- The first dose should not be administered less than 4 hours after the patient last used a short-acting opioid product, or 24 hours after the patient last used a long-acting opioid product, such as methadone. 2
From the Research
Buprenorphine for Opioid Withdrawal
- Buprenorphine is more effective than clonidine or lofexidine for managing opioid withdrawal in terms of severity of withdrawal, duration of withdrawal treatment, and the likelihood of treatment completion 3, 4, 5, 6.
- Buprenorphine and methadone appear to be equally effective, but data are limited 3, 4, 5, 6.
- Withdrawal symptoms may resolve more quickly with buprenorphine than with methadone 3, 4, 5, 6.
Starting Buprenorphine During Acute Opioid Withdrawal
- There is no clear evidence to suggest that buprenorphine should not be started during acute opioid withdrawal 3, 4, 5, 6.
- However, the studies included in the review did not specifically address the question of starting buprenorphine during acute opioid withdrawal 3, 4, 5, 6.
- One study suggested that buprenorphine may be more effective than clonidine or lofexidine for managing opioid withdrawal, but did not specify whether buprenorphine was started during acute withdrawal 7.
Considerations for Starting Buprenorphine
- The decision to start buprenorphine during acute opioid withdrawal should be based on individual patient needs and medical judgment 3, 4, 5, 6.
- Patients should be closely monitored for adverse effects and withdrawal symptoms when starting buprenorphine 3, 4, 5, 6.
- Further research is needed to determine the optimal timing and dosage of buprenorphine for managing opioid withdrawal 3, 4, 5, 6.