What is the recommended treatment protocol for opioid use disorder using Suboxone (buprenorphine/naloxone) in Medication-Assisted Treatment (MAT)?

Recommended Treatment Protocol for Opioid Use Disorder Using Suboxone (Buprenorphine/Naloxone) in MAT

For patients with opioid use disorder, medication-assisted treatment (MAT) with buprenorphine/naloxone (Suboxone) is essential and should be combined with behavioral therapy for optimal outcomes. 1

Initial Assessment and Diagnosis

• Conduct addiction assessment using the OUD checklist from DSM-5 before initiating treatment
• Be aware that many OUD criteria can occur due to chronic pain, potentially causing false positives 2
• Consider consultation with addiction specialist if available, as OUD can be difficult to diagnose in patients receiving long-term opioid therapy 2

Induction Phase

• Target dose: 16mg daily (range 4-24mg based on individual response) 1
• Induction protocol:
  • Patient must be in mild-moderate withdrawal before first dose (to avoid precipitated withdrawal)
  • Initial dose: 2-4mg sublingual buprenorphine/naloxone
  • May titrate up by 2-4mg increments every 1-2 hours on day 1 based on withdrawal symptoms
  • Day 2: Continue with total day 1 dose, may increase as needed
  • Stabilize on target dose of 16mg daily (range 4-24mg) 1

Stabilization and Maintenance Phase

• Weekly visits during the first month with:
  • Urine drug testing to verify adherence and detect illicit drug use
  • Assessment for medication side effects, withdrawal symptoms, and cravings 1
• Once stable, reduce visits to monthly with continued monitoring 1
• Long-term maintenance is recommended for most patients with OUD to reduce mortality risk

Behavioral Component of MAT

• MAT must include behavioral interventions such as:
  • Cognitive-behavioral therapy
  • Contingency management
  • Relapse prevention strategies
  • Motivational enhancement therapy
  • Addressing underlying triggers
  • Providing social stability support 1

Monitoring and Follow-up

• Regular urine drug testing to verify adherence and detect illicit drug use
• Assessment for medication toxicity, adverse effects, and compliance with treatment plan
• Evaluate for responsible medication handling and abstinence from illicit drugs 1
• Use state prescription drug monitoring program (PDMP) data to check for other controlled substance prescriptions 2

Special Considerations

• Pregnant women: Use buprenorphine alone (without naloxone) with coordinated obstetric care 1
• Patients with severe hepatic impairment may require dose adjustments 1
• Avoid concurrent benzodiazepine prescriptions whenever possible due to overdose risk 2
• For patients with acute pain while on buprenorphine/naloxone:
  • Continue maintenance dose
  • Consider dividing daily dose and administering every 6-8 hours to utilize analgesic properties
  • Add short-acting opioid analgesics as needed 1

Treatment Failure Management

• Patients who continue to misuse buprenorphine or other opioids should be referred to more intensive structured treatment
• Consider referral to methadone maintenance for patients with inadequate response or who fail buprenorphine treatment 1

Common Pitfalls to Avoid

• Abrupt discontinuation of buprenorphine/naloxone (increases relapse risk and withdrawal)
• Inadequate dosing (underdosing increases risk of continued illicit opioid use)
• Lack of behavioral therapy component (reduces effectiveness)
• Insufficient monitoring during early treatment phase
• Failure to address co-occurring mental health conditions
• Premature discontinuation of treatment (longer duration improves outcomes)

Buprenorphine/naloxone is preferred over buprenorphine alone for most patients due to its abuse-deterrent properties 2, and MAT with buprenorphine/naloxone has been shown to be more effective than withdrawal management alone in reducing mortality and improving quality of life for patients with OUD.