What is the recommended dosing schedule for Suboxone (buprenorphine) titration?

Suboxone (Buprenorphine) Titration Protocol

The recommended dosing schedule for Suboxone (buprenorphine) titration begins with 4-8 mg sublingual on day 1 for patients in mild to moderate withdrawal, with a target maintenance dose of 8-16 mg daily, typically divided into 2-3 doses for optimal pain control and opioid use disorder treatment. 1

Initial Assessment and Preparation

• Ensure patient is in mild to moderate opioid withdrawal (COWS score of 8-12) before first dose to avoid precipitated withdrawal
• Have naloxone available during induction due to variable rates of buprenorphine dissociation from receptors
• Screen for depression and other mental health conditions that may impact treatment

Titration Schedule for Opioid Use Disorder

Day 1:

• Initial dose: 4-8 mg sublingual when patient shows signs of withdrawal
• May give additional 2-4 mg after 1-2 hours if withdrawal symptoms persist
• Maximum Day 1 dose: 8-12 mg

Day 2:

• Give previous day's total dose as a single dose
• May increase by 2-4 mg if withdrawal symptoms or cravings persist
• Maximum Day 2 dose: 16 mg

Day 3 and beyond:

• Continue increasing by 2-4 mg daily as needed for withdrawal symptoms or cravings
• Target maintenance dose: 8-16 mg daily 1
• Maximum recommended dose: 24 mg daily (FDA guideline), though doses up to 32 mg have shown improved outcomes in recent studies 2

Alternative Approach: Low Dose Initiation

For patients unable to achieve withdrawal or at high risk of precipitated withdrawal:

• Start with very low dose (0.25-0.5 mg)
• Gradually increase over several days while continuing full opioid agonist
• This approach minimizes risk of precipitated withdrawal 3

Dosing Frequency Considerations

• Standard: Once daily dosing
• For enhanced pain control: Divide total daily dose into 2-3 doses given every 8-12 hours 1
• Example: 16 mg daily can be given as 8 mg every 12 hours or 5-6 mg every 8 hours
• Extended dosing intervals beyond 72 hours are not recommended as withdrawal symptoms significantly increase 4

Special Considerations

Pain Management

• For patients with pain: Consider divided dosing (every 8 hours) to maximize analgesic effect 1
• If pain control is inadequate with buprenorphine alone:
  1. First increase buprenorphine dose in divided doses
  2. Add non-opioid adjunctive therapies (NSAIDs, gabapentinoids)
  3. Consider adding full opioid agonist at higher doses if maximal buprenorphine dosing fails 1

Perioperative Management

For patients requiring surgery:

• For mild pain procedures: Continue buprenorphine without taper
• For moderate-severe pain procedures: Consider reducing dose to 8-12 mg 2-3 days before surgery 5
• Use multimodal analgesia and regional techniques when possible 5

Monitoring During Titration

• Assess daily for withdrawal symptoms, cravings, sedation, and respiratory depression
• Monitor for side effects: constipation, headache, insomnia, nausea
• Adjust dose based on clinical response, patient function, and side effects
• If withdrawal symptoms occur during titration, pause or delay dose changes 1

Common Pitfalls to Avoid

1. Initiating buprenorphine too early before withdrawal symptoms appear (risk of precipitated withdrawal)
2. Underdosing, leading to continued withdrawal symptoms and cravings
3. Abrupt discontinuation, which can cause withdrawal symptoms
4. Underestimating opioid tolerance, requiring higher doses for adequate control 1
5. Failing to recognize that buprenorphine's high binding affinity may require higher doses of full μ-agonists for breakthrough pain management 1

Buprenorphine titration requires careful monitoring and individualized dosing based on the patient's response, but following this structured approach will optimize outcomes for most patients with opioid use disorder or chronic pain requiring buprenorphine therapy.