What is the typical dosing for induction of Suboxone (buprenorphine/naloxone)?

From the Guidelines

The typical dosing for induction of Suboxone (buprenorphine/naloxone) starts with 2-4 mg sublingually on day one, given when the patient is in mild to moderate withdrawal, with additional doses administered as needed up to a maximum of 8 mg on the first day, as recommended by the most recent and highest quality study 1.

Key Considerations for Induction

• Patients should be in a state of withdrawal before starting Suboxone to avoid precipitated withdrawal, typically 12-24 hours after last short-acting opioid use or 36-72 hours after last methadone use.
• The presence of at least mild withdrawal symptoms should be verified by the administration of a validated opioid withdrawal scale, such as the COWS (Clinical Opiate Withdrawal Scale) score, which should ideally be ≥8 before administration 1.
• Patients should be instructed to place the medication under the tongue until completely dissolved (typically 5-10 minutes) and avoid eating, drinking, or smoking during this time to ensure proper absorption.

Dosing Schedule

• On day one, 2-4 mg of Suboxone can be administered sublingually, repeated at 2-hour intervals if well tolerated, until resolution of withdrawal symptoms, with a total dose of 4-8 mg typically needed on the first day 1.
• On day two, the total dose from day one can be given as a single dose, with possible additional doses for breakthrough withdrawal symptoms, generally not exceeding 16 mg.
• By day three, most patients are stabilized on 12-16 mg daily, though some may require up to 24 mg daily, as supported by a recent meta-analysis 1.

Important Properties of Buprenorphine

• Buprenorphine's high receptor affinity and partial agonist properties allow it to displace full opioid agonists while providing enough opioid effect to prevent withdrawal symptoms.
• The medication should be used with caution and under close monitoring, especially when switching from methadone to buprenorphine, due to the risk of precipitating withdrawal symptoms.

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 It is recommended that an adequate treatment dose, titrated to clinical effectiveness, should be achieved as rapidly as possible. The dosing on the initial day of treatment may be given in 2 mg to 4 mg increments if preferred. In a one-month study, patients received 8 mg of Buprenorphine Sublingual Tablets on Day 1 and 16 mg Buprenorphine Sublingual Tablets on Day 2.

The typical dosing for induction of Suboxone (buprenorphine/naloxone) is as follows:

• The first dose should be administered when objective and clear signs of moderate opioid withdrawal appear.
• For patients dependent on short-acting opioids, the first dose should not be less than 4 hours after the patient last used an opioid.
• The dosing on the initial day of treatment may be given in 2 mg to 4 mg increments if preferred.
• One possible dosing regimen is 8 mg on Day 1 and 16 mg on Day 2, as seen in a one-month study 2. Key points:
• The dose should be titrated to clinical effectiveness as rapidly as possible.
• The patient's level of opioid dependence and the time since last opioid use should be considered when determining the induction dose.

From the Research

Typical Dosing for Induction of Suboxone

The typical dosing for induction of Suboxone (buprenorphine/naloxone) is not explicitly stated in the provided studies. However, the studies provide information on the dosing of buprenorphine used in various clinical trials:

• A study from 1993 3 used a fixed dose schedule of buprenorphine (0.6-1.2 mg per day, sublingually) for 10 days.
• A study from 2018 4 compared the effectiveness of different doses of sublingual buprenorphine, including low-dose (0.8-2 mg per day) and high-dose (4-8 mg per day) buprenorphine.
• Other studies 5, 6, 7 do not provide specific dosing information for buprenorphine induction.

Key Findings

Some key findings from the studies include:

• Buprenorphine is effective in managing opioid withdrawal and is associated with a lower average withdrawal score and higher treatment completion rates compared to clonidine 5, 3, 7.
• Buprenorphine and methadone appear to be equally effective in managing opioid withdrawal, but data are limited 5.
• The rate of dose tapering may affect treatment outcome, but the evidence is uncertain 5.
• Buprenorphine is as effective as clonidine in controlling withdrawal symptoms, and a greater percentage of patients detoxified with buprenorphine received maintenance treatment 7.

Comparison of Buprenorphine and Clonidine

The studies compared the efficacy of buprenorphine and clonidine in opioid detoxification, with findings including:

• Buprenorphine was found to be superior to clonidine in alleviating most subjective and objective opiate withdrawal symptoms 3.
• Buprenorphine and clonidine were found to be comparable in controlling withdrawal symptoms, with no significant difference in relapse rates between the two methods 7, 4.