When should Suboxone (buprenorphine) be given to patients with opioid use disorder?

When to Administer Suboxone (Buprenorphine) for Opioid Use Disorder

Suboxone should be administered only when patients are experiencing objective and clear signs of moderate opioid withdrawal, typically not less than 4 hours after last use of short-acting opioids or 24 hours after long-acting opioids. 1

Patient Selection and Timing of Administration

Initial Assessment

• Evaluate for signs of moderate withdrawal using Clinical Opiate Withdrawal Scale (COWS):
  • Mild withdrawal: COWS score 5-12
  • Moderate withdrawal: COWS score 13-24 (optimal timing for induction)
  • Moderately severe withdrawal: COWS score 25-36
  • Severe withdrawal: COWS score >36 2

Timing Based on Previous Opioid Use

• Short-acting opioids (heroin): Wait at least 4 hours after last use 1
• Long-acting opioids (methadone): Wait at least 24 hours after last use 1
• Methadone patients: Higher risk of precipitated withdrawal, especially if maintained on >30mg daily 1

Induction Protocol

Day 1 Dosing

1. Initial dose: 2-4mg sublingual when moderate withdrawal symptoms appear 1
2. Reassess after 30-60 minutes 2
3. Additional doses may be given at 2-hour intervals if withdrawal persists 1
4. Target Day 1 dose: 8mg for most patients 1

Day 2 and Beyond

1. Target dose: 16mg daily (recommended for most patients) 3, 1
2. Dose range: 4-24mg daily depending on individual response 1
3. Doses higher than 24mg have not demonstrated clinical advantage 1

Special Considerations

Pregnant Patients

• Buprenorphine monotherapy (without naloxone) historically preferred, though recent evidence suggests combination therapy may be safe 3
• Higher and more frequent doses (2-4 times daily) may be required during pregnancy 3
• Daily dosage of 16mg is sufficient to suppress illicit opioid use in most pregnant women 3

Perioperative Management

• For patients already on buprenorphine maintenance therapy:
  • Continue their daily dose throughout treatment to prevent withdrawal 2
  • For pain management, consider dividing the daily dose into 2-3 doses 2

Risk of Precipitated Withdrawal

• Despite adequate withdrawal at induction, patients using fentanyl (knowingly or unknowingly) may experience precipitated withdrawal 4
• If precipitated withdrawal occurs, provide 2mg of buprenorphine every 1-2 hours until symptoms subside 4
• High-dose buprenorphine (up to 20mg total) may be needed to reverse precipitated withdrawal symptoms 4

Maintenance Phase

Dosing

• Adjust in increments/decrements of 2-4mg to reach optimal dose 1
• Maintenance dose range: 4-24mg daily 1
• Target maintenance dose: 16mg daily as a single dose 1

Administration Method

• Place tablets under tongue until completely dissolved 1
• Do not eat or drink until tablet is dissolved 1
• Do not cut, chew, or swallow tablets 1
• For multiple tablets: either place all at once or two at a time under the tongue 1

Monitoring and Follow-up

• Initially supervised administration, progressing to unsupervised as clinical stability permits 1
• Regular monitoring for withdrawal symptoms, cravings, and illicit opioid use 2
• No maximum recommended duration of treatment; continue as long as patient benefits 1

Common Pitfalls and How to Avoid Them

1. Premature administration: Ensure patient is in moderate withdrawal before giving first dose to prevent precipitated withdrawal 1

2. Inadequate dosing: Target 16mg daily for most patients; underdosing may lead to continued illicit opioid use 3, 1

3. Failure to recognize fentanyl-related precipitated withdrawal: With increasing prevalence of fentanyl-laced drugs, be prepared to manage precipitated withdrawal with higher doses of buprenorphine 4, 5

4. Abrupt discontinuation: Avoid stopping buprenorphine abruptly; implement gradual taper of approximately 10% of original dose per week when discontinuation is appropriate 2

5. Overlooking concurrent benzodiazepine use: While methadone may be more appropriate for patients using benzodiazepines, buprenorphine should not be withheld if it's the only accessible or preferred option 3