What are the guidelines for Suboxone (buprenorphine with naloxone) treatment in opioid use disorder?

Suboxone (Buprenorphine/Naloxone) Guidelines for Opioid Use Disorder Treatment

Medication-assisted treatment (MAT) with buprenorphine/naloxone (Suboxone) combined with behavioral therapies is the most effective first-line approach for treating opioid use disorder, reducing mortality and improving quality of life. 1

Patient Assessment and Eligibility

• Evaluate patients for opioid use disorder using DSM-5 criteria
• Screen for risk factors for overdose or complications
• Verify the patient is in mild-moderate withdrawal (COWS score >8) before first dose to avoid precipitated withdrawal 2, 1
• Assess for:
  • Concurrent benzodiazepine use (should be avoided due to increased risk of respiratory depression) 1
  • Pregnancy (Subutex/buprenorphine alone preferred over Suboxone) 1
  • Mental health status (screen for depression using PHQ-2/PHQ-9) 2
  • Comorbid neurocognitive disorders 2

Dosing Protocol

Induction Phase

• Initial dose: 2-4mg sublingual buprenorphine/naloxone 2, 1
• Maximum Day 1 dose: 8-12mg 1
• Target dose: 16mg daily (range 4-24mg based on individual response) 2, 1
• Higher doses up to 32mg/day may improve outcomes in patients with continued opioid use at 24mg, showing reduced frequency of use and improved retention 3

Maintenance Phase

• Daily dosing initially, with potential for less frequent dosing (every 2-3 days) in stable patients 1
• For chronic pain management in patients with OUD, consider:
  • Increasing dosage of buprenorphine in divided doses (4-16mg in 8-hour doses) 2
  • Switching from buprenorphine/naloxone to buprenorphine transdermal formulation 2

Monitoring and Follow-up

• Frequent visits initially (weekly for first month)
• Monthly visits once stable
• Regular urine drug testing to verify adherence and detect other substance use
• Review prescription drug monitoring program data
• Assess for side effects, cravings, and withdrawal symptoms 1

Special Populations

Pregnant Women

• Use buprenorphine alone (Subutex) instead of buprenorphine/naloxone due to theoretical risks to the fetus 1

Patients with Chronic Pain

• For inadequate pain control on buprenorphine:
  1. Increase buprenorphine in divided doses (4-16mg every 8 hours) 2
  2. Consider switching to transdermal buprenorphine formulation 2
  3. If maximum dose reached, consider adding long-acting potent opioid (fentanyl, morphine, hydromorphone) 2
  4. If unsuccessful, consider transitioning from buprenorphine to methadone maintenance 2

Patients in Acute Withdrawal

• For naloxone-precipitated withdrawal, sublingual buprenorphine can effectively treat symptoms 4
• Direct and rapid induction onto buprenorphine/naloxone is safe and well-tolerated 5

Formulations and Safety

• Buprenorphine/naloxone (Suboxone) is the preferred formulation for most patients due to abuse-deterrent properties 1, 6
• When taken sublingually as prescribed, naloxone has no significant clinical effect
• If injected by patients dependent on full opioid agonists, naloxone causes withdrawal, reducing abuse potential 6
• Buprenorphine has a ceiling effect on respiratory depression, making it safer than full opioid agonists 2

Common Pitfalls and Considerations

1. Precipitated Withdrawal: Always ensure patient is in mild-moderate withdrawal before first dose (COWS >8) 2, 1

2. Drug Interactions: Monitor for interactions that can cause:

   • QT-interval prolongation
   • Serotonin syndrome
   • Paralytic ileus
   • Reduced analgesic effect 1

3. Treatment Barriers:

   • Inadequate treatment duration
   • Failure to combine medications with behavioral approaches
   • Stigma-based treatment limitations
   • Insurance barriers 1

4. Perioperative Management: Consider the patient's daily dose, indication for treatment, risk of relapse, and expected postsurgical pain when planning perioperative management 1

5. Transitioning from Methadone: Patients on methadone require careful management when transitioning to buprenorphine due to high risk of precipitated withdrawal 1

Buprenorphine/naloxone has proven efficacy similar to methadone but with a better safety profile and more flexible administration options, making it a valuable treatment option for opioid use disorder 6, 7.