If a urine drug screen (UDS) is positive for buprenorphine (BUP), do you start Suboxone (buprenorphine/naloxone)?

Managing Buprenorphine Treatment When UDS is Positive for BUP

If a urine drug screen (UDS) is positive for buprenorphine (BUP), you should NOT start Suboxone (buprenorphine/naloxone) as this indicates the patient is already taking buprenorphine and adding more could lead to adverse effects.

Understanding a Positive BUP Test Result

A positive buprenorphine result on a UDS indicates:

• The patient is currently taking buprenorphine in some form
• Starting additional buprenorphine (Suboxone) could lead to:
  • Excessive buprenorphine levels
  • Potential adverse effects
  • Medication duplication

Clinical Approach to Positive BUP UDS

1. Verify Current Buprenorphine Treatment

• Contact the patient's methadone maintenance clinic or prescribing physician to verify:
  • Current buprenorphine dose
  • Formulation (Suboxone, Subutex, Sublocade, etc.)
  • Time of last dose 1
  • Treatment adherence history

2. Assess for Potential Sources of Buprenorphine

• Prescribed buprenorphine for OUD treatment
• Prescribed buprenorphine for pain management
• Non-prescribed (diverted) buprenorphine use
• Buprenorphine from another provider

3. Clinical Decision Making

If Patient Has Legitimate Prescription:

• Continue the patient's established buprenorphine regimen
• Avoid adding additional buprenorphine/naloxone 1
• Consider dose adjustments only if clinically indicated for pain or OUD management 1

If Using Non-prescribed Buprenorphine:

• Evaluate for opioid use disorder
• Consider formal initiation of appropriate buprenorphine/naloxone treatment
• Document assessment of OUD using DSM-5 criteria 1

Special Considerations

For Pain Management

• If the patient is already on buprenorphine and experiencing pain:
  • Continue the maintenance buprenorphine dose
  • Consider dividing the buprenorphine dose to every 6-8 hours for better pain control 1
  • Add appropriate non-opioid analgesics 1
  • For severe pain, higher doses of buprenorphine may be needed (4-16 mg divided into 8-hour doses) 1

For OUD Treatment Optimization

• If the patient is self-treating OUD with non-prescribed buprenorphine:
  • Formalize treatment with appropriate prescribing
  • Establish proper monitoring and follow-up
  • Consider buprenorphine/naloxone (Suboxone) as the preferred formulation to reduce diversion potential 2, 3

Common Pitfalls to Avoid

1. Adding Suboxone to existing buprenorphine therapy - This can lead to excessive dosing and side effects

2. Assuming illicit use - Many patients self-treat OUD with diverted buprenorphine due to barriers to formal treatment 4

3. Abrupt discontinuation - Never abruptly stop buprenorphine as this can precipitate withdrawal 1, 2

4. Failing to verify current treatment - Always contact the existing prescriber before making treatment decisions 1

5. Overlooking pain management needs - Patients on buprenorphine for OUD may still require pain management 1

By following this approach, you can ensure appropriate management of patients who show buprenorphine in their urine drug screen while avoiding medication duplication and potential adverse effects.