What is the recommended treatment plan for a patient receiving Suboxone (buprenorphine) for opioid use disorder at a clinic?

Recommended Treatment Plan for Suboxone (Buprenorphine) in Clinic Settings

Clinicians providing Suboxone for opioid use disorder should offer medication-assisted treatment combining buprenorphine with behavioral therapies, maintain patients on long-term maintenance therapy rather than brief tapers, and ensure regular monitoring with follow-up visits at least every 3 months. 1

Core Treatment Framework

Medication-Assisted Treatment as Standard of Care

• Buprenorphine should be combined with behavioral therapies as the evidence-based standard for opioid use disorder treatment 1
• Longer-term maintenance treatment is strongly preferred over brief medication tapers or medical withdrawal, which are associated with high relapse rates 1
• The goal is sustained treatment retention and reduction in illicit opioid use, not necessarily immediate abstinence 2

Dosing Strategy

• Target maintenance doses of 16 mg/day sublingual buprenorphine/naloxone, as this dosage is clearly superior to placebo and as effective as methadone 3
• Doses up to 24-32 mg/day are safe and may improve outcomes, particularly for patients with continued opioid use or cravings 2
• Recent evidence shows that increasing from 24 mg to 32 mg/day significantly reduces opioid use (68.5% to 59.5%), frequency of use, and physiologic triggers for use 2
• Use the lowest effective dosage, but do not hesitate to titrate upward if patients show inadequate response 4, 3

Monitoring and Follow-Up Schedule

Patients must be seen at minimum every 3 months, though more frequent visits are appropriate during initial stabilization 1

Each follow-up visit should include:

• Documentation of any relapses or continued opioid use 3
• Assessment for reemergence of cravings or withdrawal symptoms 3
• Random urine drug testing 3
• Pill or wrapper counts to verify adherence 3
• Review of state prescription drug monitoring program (PDMP) data for high-risk combinations or dosages 1

Managing Continued Opioid Use

• Sporadic opioid use during the first few months is not uncommon and should not be considered treatment failure 3
• Address continued use by increasing visit frequency and intensifying engagement with behavioral therapies 3
• Higher doses (up to 32 mg/day) may be warranted for patients with persistent use 2

Provider Requirements and Practice Structure

Waiver Requirements (Note: Regulations have evolved)

• Physicians must obtain a Drug Addiction Treatment Act (DATA) waiver from SAMHSA to prescribe buprenorphine for opioid use disorder 1
• Clinicians in communities without sufficient treatment capacity should strongly consider obtaining this waiver 1
• No waiver is required to prescribe naltrexone 1

Integration into Primary Care

• Buprenorphine treatment integrates well into family medicine continuity clinics and provides substantial primary care experience 5
• Approximately 66% of MAT patients use their buprenorphine provider as their primary care physician 5
• These patients average 2.3 chronic comorbidities requiring management, with 69% having mood disorders and an average of 1.5 non-psychiatric comorbidities 5

Special Considerations and Pitfalls

Avoid Patient Abandonment

• Never dismiss patients from your practice because of substance use disorder, as this adversely affects patient safety and represents patient abandonment 1
• If unable to provide treatment directly, arrange for care with a substance use disorder specialist or SAMHSA-certified opioid treatment program 1
• Assist patients in finding qualified providers and arrange ongoing care coordination 1

Concurrent Benzodiazepine Use

• Avoid concurrent opioids and benzodiazepines whenever possible due to risk of fatal respiratory depression 1
• If tapering is needed, it may be safer to taper opioids first 1
• Offer evidence-based psychotherapies (CBT) and non-benzodiazepine medications for anxiety when tapering benzodiazepines 1

Formulation Selection

• Buprenorphine/naloxone combination products (Suboxone) are preferred over buprenorphine alone due to the naloxone component preventing misuse by injection 1
• For pregnant women with opioid use disorder, use buprenorphine without naloxone 1

Long-Acting Injectable Formulations

• Sublocade (extended-release buprenorphine) requires prior stabilization on 8-24 mg/day of sublingual buprenorphine for at least 7 consecutive days 6
• Initial dosing is 300 mg monthly for two months, followed by 100 mg monthly maintenance 6
• Long-acting formulations may decrease diversion risk and improve adherence 7

Managing Acute Pain in Patients on Buprenorphine

• Buprenorphine's high receptor affinity can complicate acute pain management 1
• Consider high-potency opioids like fentanyl or hydromorphone when additional analgesia is needed 1
• For chronic pain management, transdermal buprenorphine may provide better analgesia than sublingual formulations 1

Comprehensive Care Components

Psychosocial Support

• Screen all patients for depression using validated tools like PHQ-9 1
• Assess baseline mental health status for modifiable factors including mood disorders, history of violence, and suicidal ideation 1
• Coordinate with mental health professionals managing the patient 1

Harm Reduction

• Offer overdose prevention education and take-home naloxone kits 1
• Provide hepatitis C and HIV screening 1
• Offer reproductive health counseling 1