From the Guidelines
To avoid significant opioid withdrawal symptoms during the first 36 hours before starting Suboxone (buprenorphine) treatment, patients should abstain from short-acting opioids for at least 12-24 hours and long-acting opioids for 36-48 hours before induction. This approach is recommended to ensure that patients are experiencing opioid withdrawal, which is necessary for the initiation of buprenorphine treatment 1.
The treatment regimen to manage withdrawal symptoms during this period can include a combination of non-opioid medications, such as:
- Clonidine 0.1-0.2 mg every 4-6 hours as needed for autonomic symptoms like sweating and anxiety
- Loperamide 4 mg initially followed by 2 mg after each loose stool (maximum 16 mg/day) for diarrhea
- NSAIDs such as ibuprofen 400-600 mg every 6 hours or acetaminophen 500-1000 mg every 6 hours for muscle aches and pain
- Hydroxyzine 25-50 mg every 6 hours as needed for anxiety and insomnia
- Ondansetron 4-8 mg every 8 hours for nausea and vomiting
These medications target specific withdrawal symptoms without using opioids, providing symptomatic relief while the patient reaches the appropriate level of withdrawal for safe Suboxone induction 1. It is essential to verify the presence of at least mild withdrawal symptoms using a validated opioid withdrawal scale before initiating buprenorphine treatment.
The dosage of buprenorphine can vary, but a daily dosage of 16 mg is sufficient to suppress illicit opioid use in most patients with opioid use disorder (OUD) 1. However, the dosage may need to be adjusted based on individual patient needs, and higher doses may be required during pregnancy.
In patients who are unable to tolerate buprenorphine or in whom buprenorphine is found to be ineffective, methadone is recommended 1. However, switching from methadone to buprenorphine can be challenging due to the risk of precipitating withdrawal symptoms.
From the Research
Treatment Regimen for Opioid Withdrawal
To avoid significant opioid withdrawal symptoms for the first 36 hours prior to Suboxone (buprenorphine) treatment, the following treatment regimens can be considered:
- Clonidine: Clonidine hydrochloride, an alpha-adrenergic agonist, can rapidly suppress the signs and symptoms associated with opiate withdrawal 2.
- Buprenorphine: Buprenorphine is more effective than clonidine for managing opioid withdrawal in terms of severity of withdrawal, duration of withdrawal treatment, and the likelihood of treatment completion 3, 4.
- Methadone: Methadone and buprenorphine appear to be equally effective for managing opioid withdrawal, but data are limited 3, 4.
Comparison of Treatment Regimens
The following comparisons can be made between the treatment regimens:
- Buprenorphine vs. Clonidine: Buprenorphine is more effective than clonidine in ameliorating the symptoms of withdrawal, and patients treated with buprenorphine stay in treatment for longer 3, 4.
- Buprenorphine vs. Methadone: Buprenorphine and methadone appear to be equally effective, but withdrawal symptoms may resolve more quickly with buprenorphine 3, 4.
Special Considerations
The following special considerations should be taken into account:
- Loperamide use disorder: Buprenorphine can be used to manage patients with loperamide-associated withdrawal and help them remain abstinent upon discharge 5, 6.
- Waiting time before starting buprenorphine treatment: Different waiting times may be necessary before starting buprenorphine treatment to avoid precipitated withdrawal 5.