When should a patient be induced onto Suboxone (buprenorphine/naloxone)?

When to Induce a Patient on Suboxone

Initiate Suboxone (buprenorphine/naloxone) only when the patient is in active opioid withdrawal with a Clinical Opiate Withdrawal Scale (COWS) score >8, ensuring adequate time has elapsed since last opioid use: >12 hours for short-acting opioids, >24 hours for extended-release formulations, and >72 hours for methadone. 1

Pre-Induction Timing Requirements

The critical determinant for Suboxone induction is the presence of objective and clear signs of moderate opioid withdrawal, not simply patient request or desire to start treatment 2. The timing varies based on the type of opioid:

Short-Acting Opioids (Heroin, Morphine IR, Oxycodone IR)

• Wait at least 12 hours since last use 1
• FDA labeling specifies not less than 4 hours as the absolute minimum, though 12+ hours is preferred 2
• Confirm withdrawal symptoms are present before administering the first dose 3

Extended-Release Opioids (OxyContin, MS Contin)

• Wait at least 24 hours since last use 1
• These formulations require longer clearance time to avoid precipitated withdrawal 2

Methadone or Long-Acting Opioids

• Wait at least 24 hours, and generally not less than 24 hours after last dose 2
• For methadone maintenance patients, wait >72 hours 1
• Patients on higher methadone doses (>30 mg) are at increased risk of precipitated withdrawal 2
• Withdrawal symptoms appear more likely when buprenorphine is given shortly after the last methadone dose 2

Confirming Readiness for Induction

Mandatory Assessment

• Use a validated opioid withdrawal scale (COWS) to confirm at least mild withdrawal symptoms 3
• Target COWS score >8 before initiating 1
• Reassess COWS 30 minutes after the initial dose to ensure tolerance 3

Critical Safety Screening

• Do not administer to intoxicated patients 1
• Screen for QT-prolonging medications as concomitant use is contraindicated due to cardiac arrhythmia risk 3, 1
• Assess for concurrent benzodiazepine or CNS depressant use, though this should not automatically exclude patients from treatment 3

Standard Induction Protocol

Initial Dosing

• Start with 4-8 mg sublingual based on withdrawal severity 1, 2
• Reassess after 30-60 minutes for response 1
• Additional 2-4 mg increments can be given on Day 1 if needed 2
• Target total first-day dose of 16 mg for most patients 1, 2

Day 2 and Beyond

• Administer 16 mg on Day 2 2
• Rapid dose escalation to adequate treatment dose minimizes dropout during induction 2
• Gradual induction over several days has been associated with high dropout rates 2

Maintenance Dosing

• Typical maintenance range: 4-24 mg daily 3, 2
• Recommended target: 16 mg daily 3, 1, 2
• Doses >24 mg have not demonstrated clinical advantage 2

Special Populations and Alternative Approaches

Pregnant Patients

• Same induction principles apply: must be in withdrawal before initiating 3
• Abstain from short-acting opioids 12-24 hours before induction 3
• Abstain from long-acting opioids 36-48 hours before induction 3
• Verify mild withdrawal with validated scale before first dose 3

Patients Unable to Tolerate Withdrawal (Microinduction)

• For patients averse to withdrawal, on high-dose methadone, or using fentanyl, microinduction (starting with 0.2-0.5 mg doses) allows gradual transition without stopping full agonists 4
• Low-dose IV buprenorphine induction permits immediate initiation without withdrawal or stopping pain medications, with 90.9% completion rates in hospitalized patients 5
• These alternative methods typically transition patients over 4-8 days to therapeutic doses of 8-16 mg 4, 6

Common Pitfalls to Avoid

Precipitated Withdrawal Risk

• Never administer buprenorphine before adequate withdrawal onset - this is the most common cause of precipitated withdrawal 2
• Buprenorphine's high receptor affinity displaces full agonists, causing acute withdrawal if given too soon 4, 6
• This risk is particularly high with methadone due to its long half-life 2

Delaying Treatment

• Do not delay induction for drug testing when a patient presents in active withdrawal and meets clinical criteria 1
• Drug testing showing polysubstance use should not prevent treatment initiation 1
• Concurrent benzodiazepine use is not an absolute contraindication, though requires careful monitoring 3

Inadequate Dosing

• Underdosing during induction increases dropout risk 2
• Achieve adequate treatment dose as rapidly as possible 2
• Most patients require 16 mg daily to suppress illicit opioid use 3, 1

Administration Technique

• Tablets must be placed under the tongue until completely dissolved 2
• Do not cut, chew, or swallow tablets 2
• Advise patients not to eat or drink until tablet is dissolved 2
• For doses requiring >2 tablets, place all at once or two at a time under tongue 2

Post-Induction Considerations

• Provide overdose prevention education and take-home naloxone 1
• Offer hepatitis C and HIV screening 1
• Monitor for respiratory depression, especially during dose increases 1
• Watch for serotonin syndrome if combined with serotonergic agents 3, 1
• Treatment duration should be indefinite as long as patients benefit 2