What is the recommended protocol for prescribing Suboxone (buprenorphine) for opioid use disorder?

Protocol for Prescribing Suboxone (Buprenorphine) for Opioid Use Disorder

Buprenorphine (Suboxone) should be prescribed only after confirming active opioid withdrawal, starting with an initial dose of 4-8 mg sublingually, and targeting a maintenance dose of 16 mg daily for most patients with opioid use disorder. 1

Initial Assessment and Induction

Confirm Opioid Withdrawal

• Verify time since last opioid use:
  • Short-acting opioids (heroin, morphine): >12 hours
  • Extended-release formulations: >24 hours
  • Methadone maintenance: >72 hours 1
• Assess withdrawal severity using Clinical Opiate Withdrawal Scale (COWS)
  • Mild withdrawal (COWS <8): No buprenorphine indicated yet
  • Moderate to severe withdrawal (COWS >8): Proceed with induction 1

Initial Dosing

• For moderate to severe withdrawal:
  • Give buprenorphine 4-8 mg SL based on severity of withdrawal
  • Reassess after 30-60 minutes
  • Additional doses may be given if withdrawal symptoms persist 1

Maintenance Dosing

Target Dose

• Target 16 mg SL daily for most patients 1
• Range typically 4-24 mg daily, with sufficient dosage to suppress illicit opioid use 1
• Higher doses (up to 32 mg) may be needed for patients using high-potency opioids like fentanyl 2
  • Recent evidence shows improved outcomes with 32 mg dosing, including reduced opioid use frequency and better treatment retention 2

Dosing Schedule

• Once daily dosing is standard for most patients
• Can be divided into 8-hour doses (every 6-8 hours) for patients with chronic pain 1
• Pregnant women may require higher and more frequent doses (2-4 times daily) 1

Special Considerations

Formulation Selection

• For most patients: Buprenorphine/naloxone (Suboxone, Bunavail, Zubsolv)
• For pregnant women: Historically buprenorphine monotherapy (Subutex) was preferred, though limited data suggest buprenorphine/naloxone may also be safe 1

Drug Interactions

• Avoid concomitant use with QT-prolonging agents (contraindicated) 1
• Use caution with benzodiazepines and other CNS depressants
  • When both methadone and buprenorphine are available, methadone may be more appropriate if there is concurrent benzodiazepine use 1
  • However, buprenorphine should not be withheld from patients using benzodiazepines when it's the only accessible option 1

Perioperative Management

• Decision to continue or hold buprenorphine perioperatively should be individualized based on:
  • Daily dose
  • Indication (pain vs. dependency)
  • Risk of relapse
  • Expected level of post-surgical pain 1

Discharge Planning and Follow-up

Prescription Guidelines

• X-waivered providers: Prescribe 16 mg SL buprenorphine/naloxone daily for 3-7 days until follow-up
• Non-X-waivered providers: Patients may return for up to 3 consecutive days for interim treatment 1

Sample Prescription

• Buprenorphine/naloxone 8 mg/2 mg SL tablet or film
• Take 2 tablets/films once daily in AM
• Dispense #6
• No refills 1

Comprehensive Care

• Provide overdose prevention education and take-home naloxone kit
• Screen for hepatitis C and HIV
• Offer reproductive health counseling 1
• Consider adjunctive counseling, particularly for patients with comorbid PTSD 3

Common Pitfalls to Avoid

1. Precipitated withdrawal: Administering buprenorphine before patient is in sufficient withdrawal can cause severe symptoms due to buprenorphine's high binding affinity 1

2. Inadequate dosing: Underdosing is common and leads to continued illicit use. Recent evidence supports doses up to 32 mg when needed 2

3. Neglecting psychosocial support: While medication is the foundation of treatment, adding behavioral therapy like Individual Opioid Drug Counseling improves outcomes, especially for patients with comorbidities like PTSD 3

4. Abrupt discontinuation: Buprenorphine should not be stopped abruptly; treatment is typically long-term for best outcomes

5. Failure to recognize need for dose adjustment: Pregnancy, high-potency opioid use (fentanyl), and chronic pain may all require dose adjustments or split dosing 1, 2