When is Suboxone (buprenorphine) given to patients?

When Suboxone (Buprenorphine) is Given to Patients

Suboxone (buprenorphine/naloxone) is primarily given for the treatment of opioid use disorder (OUD) and for managing opioid withdrawal symptoms in patients dependent on opioids. 1, 2, 3

Primary Indications for Suboxone

1. Treatment of Opioid Use Disorder

• Maintenance therapy: Long-term treatment to prevent relapse in patients with OUD
• Induction therapy: Initial treatment to transition patients from illicit opioids to medication-assisted treatment
• Reduces illicit opioid use by approximately 80% in patients who remain in treatment 2

2. Management of Opioid Withdrawal

• Given to alleviate withdrawal symptoms in patients experiencing opioid withdrawal
• Administered when objective signs of moderate opioid withdrawal appear:
  • For short-acting opioids (e.g., heroin): Not less than 4 hours after last use
  • For long-acting opioids (e.g., methadone): Not less than 24 hours after last use 1, 3

Administration Protocol

Induction Phase

1. Initial dosing:

   • Start with 4-8mg sublingually on first day
   • May be given in 2-4mg increments
   • Target 16mg total first-day dose 2, 3
   • Must be administered only when patient shows clear signs of moderate withdrawal 1, 3

2. Special considerations:

   • Patients dependent on methadone or long-acting opioids are more susceptible to precipitated withdrawal
   • Higher risk in patients maintained on >30mg methadone 3

Maintenance Phase

• Recommended target dosage: 16mg as a single daily dose
• Typical range: 4-24mg per day depending on individual patient needs
• Duration: No maximum recommended duration; treatment may continue indefinitely as long as patient benefits 3

Clinical Settings for Administration

1. Emergency Department:

   • For patients in acute opioid withdrawal
   • Any DEA-licensed physician may administer (but not prescribe) buprenorphine for up to 72 hours while arranging referral for treatment 1
   • Limited to one day's medication at a time

2. Office-Based Treatment:

   • Requires providers to have obtained a waiver under the Drug Addiction Treatment Act
   • Preferred setting for ongoing maintenance therapy 2, 3

3. Acute Pain Management:

   • For patients already on buprenorphine maintenance therapy who develop acute pain
   • Options include:
     • Continuing maintenance therapy and titrating short-acting opioid analgesics
     • Dividing daily buprenorphine dose and administering every 6-8 hours
     • Temporarily discontinuing buprenorphine and treating with full opioid agonists 1

Contraindications and Cautions

• Do not administer if patient is not in active withdrawal, as it may precipitate severe withdrawal symptoms 1
• Avoid mixed agonist-antagonist opioids (pentazocine, nalbuphine, butorphanol) as they may precipitate withdrawal 1
• Monitor closely when used in patients with hepatic impairment 2
• Use with extreme caution in patients taking benzodiazepines due to nearly four-fold increased overdose risk 2

Formulations

• Buprenorphine sublingual tablets: Preferred for induction phase
• Buprenorphine/naloxone (Suboxone): Preferred for maintenance therapy due to reduced abuse potential 3, 4
• The naloxone component has no significant effect when taken sublingually as prescribed but causes withdrawal if injected, reducing diversion potential 4

Effectiveness

• Similar efficacy to methadone for OUD treatment 2, 4
• More effective than clonidine for medically-supervised withdrawal 4
• Reduces hospitalization and emergency room visits by 45% and 23% respectively in the first year of treatment 5

Suboxone represents an effective outpatient alternative to traditional methadone clinic treatment, allowing for more flexible dosing schedules and improved patient access to care for opioid dependence 5, 6.