Medication-Assisted Treatment (MAT) with Suboxone for Opioid Use Disorder
Buprenorphine/naloxone (Suboxone) is the recommended first-line medication for office-based treatment of opioid use disorder, with a target dose of 16mg daily (range 4-24mg based on individual response), combined with behavioral therapy. 1
Initiation and Dosing
Induction Phase
- Begin when patient shows moderate withdrawal symptoms (COWS score ≥8)
- Initial dose: 2-4mg sublingual buprenorphine
- May titrate up by 2-4mg every 1-2 hours on first day to control withdrawal symptoms
- Day 1 target: 8-12mg total
- Day 2: Administer total day 1 dose, may increase to 16mg if needed
Maintenance Phase
- Target dose: 16mg daily (range 4-24mg based on individual response)
- Once stabilized, may consider less frequent dosing (e.g., alternate-day dosing)
- Patients with severe hepatic impairment require dose reduction by half 2
Monitoring and Follow-up
Early Treatment
- Weekly visits during first month
- Urine drug testing to verify adherence and detect illicit drug use
- Assess for medication side effects, withdrawal symptoms, and cravings
Stabilized Treatment
- Once stable (no illicit drug use, stable dose), may reduce to monthly visits 2
- Continue regular urine drug testing
- Assess for:
- Absence of medication toxicity
- Absence of adverse effects
- Responsible medication handling
- Compliance with treatment plan
- Abstinence from illicit drugs 2
Behavioral Components
The CDC and other guidelines emphasize that MAT should always include behavioral interventions 3, 1:
- Cognitive-behavioral therapy
- Contingency management
- Relapse prevention strategies
- Motivational enhancement therapy
- Addressing underlying triggers and providing social stability support
Treatment Duration
- Maintenance treatment typically lasts months to years 1
- Discontinuation should only be considered as part of a comprehensive treatment plan
- Taper should be slow (10% per month or slower) to reduce withdrawal symptoms 1
- Patients should be warned about high relapse risk after discontinuation 2
Special Considerations
Pain Management
For patients on buprenorphine/naloxone with acute pain:
- Continue maintenance dose of buprenorphine
- Add short-acting opioid analgesics as needed 3
- Consider dividing the daily buprenorphine dose and administering every 6-8 hours to utilize its analgesic properties 3
Pregnancy
- Use buprenorphine alone (Subutex, without naloxone) in pregnant women 1
- Coordinate care with obstetric providers
Unstable Patients
- Patients who continue to misuse buprenorphine or other opioids should be referred to more intensive structured treatment 2
- Consider referral to methadone maintenance for patients with inadequate analgesia or who fail buprenorphine treatment 3
Advantages of Buprenorphine/Naloxone
- Office-based treatment (unlike methadone which requires specialized clinics)
- Lower risk of respiratory depression due to ceiling effect
- Reduced abuse potential due to naloxone component
- Better retention in treatment compared to abstinence-based approaches
- Studies show 41% of patients are retained in treatment for at least 6 months 4
Common Pitfalls to Avoid
- Inadequate induction: Starting too early (before withdrawal) or at too high a dose can precipitate withdrawal
- Insufficient dosing: Underdosing leads to continued cravings and potential relapse
- Lack of behavioral support: Medication alone is less effective than combined approaches
- Abrupt discontinuation: Can lead to withdrawal and increased relapse risk 2
- Ignoring comorbidities: Mental health conditions often co-occur and require treatment
By following this evidence-based approach to MAT with Suboxone, providers can significantly improve outcomes for patients with opioid use disorder, reducing mortality, morbidity, and improving quality of life.