What is the dosage and treatment plan for Suboxone (Buprenorphine-Naloxone) for opioid use disorder?

Buprenorphine-Naloxone (Suboxone) Dosing and Treatment Plan for Opioid Use Disorder

For patients with opioid use disorder, the recommended treatment plan includes buprenorphine-naloxone (Suboxone) induction starting with 4-8mg on day 1, increasing to 16mg on day 2, with a maintenance dose of 16mg daily (range 4-24mg) based on individual response. 1, 2

Induction Phase

For patients dependent on short-acting opioids (e.g., heroin):

• Wait until patient shows clear signs of moderate opioid withdrawal (typically 12-24 hours after last use)
• Day 1: Initial dose of 4-8mg sublingual buprenorphine
  • May give in 2-4mg increments if preferred
  • Target first-day dose: 8mg
• Day 2: Increase to 16mg buprenorphine

For patients dependent on long-acting opioids (e.g., methadone):

• Wait until patient shows clear signs of moderate opioid withdrawal (typically at least 24-36 hours after last use)
• More susceptible to precipitated withdrawal; use caution
• Withdrawal more likely in patients on higher methadone doses (>30mg)
• Use same dosing approach but with more careful titration

Maintenance Phase

• Target dose: 16mg daily as a single dose
• Effective range: 4-24mg daily (doses above 24mg provide no additional clinical benefit) 2
• Adjust in increments/decrements of 2-4mg to suppress withdrawal symptoms and cravings
• Buprenorphine/naloxone combination (Suboxone) is preferred for maintenance treatment 2

Administration Instructions

• Place tablet/film under tongue until completely dissolved (5-10 minutes)
• Do not eat, drink, or swallow until completely dissolved
• For multiple tablets, either place all at once or two at a time under the tongue
• Maintain consistent administration technique

Monitoring and Follow-up

• Initial phase: Weekly visits recommended
• Once stable: Monthly visits
• Regular urine drug testing to verify adherence
• Check prescription drug monitoring program
• Assess for side effects: sedation, constipation, headache, sexual dysfunction, weight gain 3

Special Considerations

Pregnant women:

• Buprenorphine monotherapy (without naloxone) is traditionally preferred, though recent evidence suggests combination therapy may also be safe 4
• Higher and more frequent dosing may be required during pregnancy

Perioperative management:

• Decision to continue or hold should be individualized based on:
  • Daily dose
  • Indication for treatment (pain vs. dependency)
  • Risk of relapse
  • Expected level of post-surgical pain 4

Benzodiazepine use:

• Increases overdose risk nearly four-fold
• Requires enhanced monitoring of vital signs, particularly respiratory rate
• Consider prescribing naloxone and educating on its use
• Do not abruptly discontinue Suboxone in these patients 1

Common Pitfalls to Avoid

1. Inadequate induction: Starting buprenorphine too early can precipitate withdrawal; ensure patient is in moderate withdrawal first

2. Insufficient dosing: Underdosing leads to continued cravings and potential relapse; target 16mg daily for most patients

3. Poor monitoring: Regular follow-up is essential to ensure treatment adherence and address side effects

4. Abrupt discontinuation: Leads to withdrawal, relapse to full agonist opioids, and increased overdose risk

5. Ignoring concurrent substance use: Particularly benzodiazepines, which significantly increase overdose risk

Treatment Duration

There is no maximum recommended duration of maintenance treatment. Patients may require treatment indefinitely and should continue as long as they are benefiting from therapy 2.