Is it safe to initiate Suboxone (buprenorphine) in a patient with opioids in their system?

From the Guidelines

It is not safe to initiate Suboxone (buprenorphine) in a patient who has active opioids in their system, as this can precipitate acute withdrawal. Patients should be in mild to moderate withdrawal before starting Suboxone, typically waiting at least 12-24 hours after short-acting opioids (like heroin or oxycodone) or 36-72 hours after long-acting opioids (like methadone) 1.

Key Considerations

• Clinicians should use the Clinical Opiate Withdrawal Scale (COWS) to assess withdrawal, with a score of at least 8-12 indicating it's safe to start treatment.
• The initial dose is typically 2-4mg of Suboxone, with additional doses as needed up to 8-16mg on the first day.
• This protocol is necessary because buprenorphine is a partial opioid agonist with high receptor affinity that will displace full agonist opioids from receptors without fully activating them, potentially causing sudden and severe withdrawal symptoms including agitation, vomiting, diarrhea, and severe pain 1.

Precipitated Withdrawal

• This phenomenon, called precipitated withdrawal, can be extremely distressing and potentially dangerous for patients.
• Particular care is required when transitioning from methadone to buprenorphine because of the risk of severe and prolonged precipitated withdrawal 1.

Monitoring and Dosing

• Comprehensive data on buprenorphine dosing in opioid withdrawal are evolving, and monitoring best practices related to buprenorphine is prudent as these are continuing to evolve 1.
• A daily dosage of 16 mg is sufficient to suppress illicit opioid use in most patients with OUD, but sufficient dosages vary and can range from 4-24 mg daily 1.

From the Research

Initiating Suboxone with Opioids in the System

• The safety of initiating Suboxone (buprenorphine) in a patient with opioids in their system is a topic of ongoing research and debate 2, 3, 4.
• Traditional practice guidelines recommend a period of mild-to-moderate withdrawal from opioids before transitioning to buprenorphine due to its ability to displace full agonists from the μ-opioid receptor 3.
• However, novel initiation strategies suggest that concomitant administration of small doses of buprenorphine with opioids can avoid the unwanted withdrawal associated with buprenorphine initiation 2, 3, 4.
• A systematic review of 15 case reports/series found that transition to buprenorphine with complete cessation of opioid agonists was achieved in 87.5% of cases, but withdrawal during initiation occurred in 58.3% of cases, with two cases being at least moderate in severity 2.
• Another systematic review of 7 observational studies, 1 feasibility study, and 39 case reports/series found that 95.6% of patients in the traditional initiation group and 96% of patients in the microdosing group successfully rotated to sublingual buprenorphine 3.
• An updated systematic review of 59 studies and 682 patients found that approximately half of patients experienced any level of withdrawal, and 7% experienced clinically significant withdrawal 4.
• The prevalence of buprenorphine dosing strategies that aim to omit prerequisite opioid withdrawal has vastly increased over the past 4 years, but the quality of evidence remains low, highlighting the need for prospective, controlled studies 4.

Key Findings

• Buprenorphine initiation strategies that omit prerequisite withdrawal have emerged as a potential alternative to traditional methods 2, 3, 4.
• Microdosing and bridging with a buprenorphine patch are common strategies reported in the literature 2, 3.
• Withdrawal during initiation is common, but most often mild in severity 2, 4.
• The need for prospective, controlled studies to inform the efficacy and safety of these strategies is highlighted by the low quality of evidence currently available 2, 4.