In-Office Buprenorphine Induction Protocol for Opioid Use Disorder
Pre-Induction Requirements
The patient must be in active opioid withdrawal before administering buprenorphine to avoid precipitated withdrawal. 1
Timing Based on Last Opioid Use
- Short-acting opioids (heroin, oxycodone): Wait at least 4 hours after last use 2
- Long-acting opioids (extended-release formulations like OxyContin): Wait more than 24 hours 1
- Methadone maintenance: Wait more than 72 hours (consider methadone treatment instead for these patients) 1
Critical caveat: Patients on methadone, especially doses >30 mg daily, are at high risk for severe precipitated withdrawal when transitioning to buprenorphine. 2
Withdrawal Assessment
Use the Clinical Opiate Withdrawal Scale (COWS) to objectively confirm withdrawal severity before any buprenorphine administration. 1, 3
Decision Algorithm Based on COWS Score
| COWS Score | Action |
|---|---|
| <8 (Mild or less) | Do NOT give buprenorphine. Reassess patient and COWS in 1-2 hours [1,3] |
| ≥8 (Moderate to severe) | Administer buprenorphine 4-8 mg sublingual based on withdrawal severity [1,3] |
Initial Dosing Protocol
For patients with COWS ≥8, administer 4-8 mg sublingual buprenorphine as the first dose. 1, 3
- Day 1: Give 8 mg buprenorphine sublingual 2
- Day 2: Give 16 mg buprenorphine sublingual 2
- Reassess after 30-60 minutes following each dose to determine if additional dosing is needed 1, 3
Alternative gradual approach: The initial day dose may be given in 2-4 mg increments if preferred, though gradual induction over several days leads to higher dropout rates. 2
Target Maintenance Dose
The recommended target dosage is 16 mg buprenorphine daily, with most patients requiring 4-24 mg daily for maintenance. 2
- Doses higher than 24 mg have not demonstrated clinical advantage 2
- The goal is to achieve an adequate treatment dose as rapidly as possible to improve retention 2
Discharge Planning and Prescribing
For X-Waivered Providers (or post-2023 elimination of X-waiver requirement)
Prescribe 16 mg sublingual buprenorphine/naloxone daily for 3-7 days, or until follow-up appointment. 1, 3
Sample prescription:
- Buprenorphine/naloxone 8 mg/2 mg sublingual tablet or film
- Take 2 tablets/films once daily in AM
- Dispense #6
- No refills 1
For Non-Waivered Providers
Patients may return for up to 3 consecutive days for interim treatment while arranging referral to a qualified provider. 1, 3
Administration Method
Buprenorphine sublingual tablets must be placed under the tongue until completely dissolved. 2
- Do NOT cut, chew, or swallow tablets 2
- Patients should not eat or drink until tablet is fully dissolved 2
- Administer as a single daily dose 2
Transition to Maintenance
After Day 2-3 induction, transition to buprenorphine/naloxone combination products (sublingual film or tablet) for ongoing maintenance treatment. 2
- Buprenorphine-only formulations (without naloxone) are preferred only during induction 2
- The naloxone component in combination products deters intravenous misuse during unsupervised administration 2
Additional Preventative Measures
Strongly consider offering at discharge: 1
- Overdose prevention education
- Take-home naloxone kit
- Hepatitis C and HIV screening
- Reproductive health counseling
Critical Warnings
Buprenorphine's high binding affinity and partial agonist properties will induce significant withdrawal if given to patients currently receiving opioids who are not yet in withdrawal. 1
Particular care is required when transitioning from methadone due to risk of severe and prolonged precipitated withdrawal. 1
Common pitfall: Administering buprenorphine too soon after last opioid use, especially with long-acting opioids or methadone, precipitates severe withdrawal and causes treatment dropout. Always confirm objective withdrawal signs with COWS scoring before first dose. 1, 2