What is the recommended protocol for treating opioid use disorder with Suboxone (buprenorphine/naloxone)?

Suboxone Protocol for Opioid Use Disorder

For standard buprenorphine/naloxone induction, patients must abstain from short-acting opioids for 12-24 hours and long-acting opioids for 36-48 hours, then demonstrate at least mild withdrawal symptoms on a validated scale before receiving the first dose to avoid precipitated withdrawal. 1

Standard Induction Protocol

Pre-Induction Requirements

• Verify withdrawal symptoms using a validated opioid withdrawal scale (e.g., COWS score ≥8-12) before administering any buprenorphine 1
• Abstinence periods are mandatory: 12-24 hours for short-acting opioids (heroin, oxycodone), 36-48 hours for long-acting opioids (methadone, extended-release formulations) 1
• Failure to wait for adequate withdrawal will precipitate severe withdrawal symptoms due to buprenorphine's partial agonist properties displacing full agonists from opioid receptors 1

Day 1 Dosing

• Administer initial dose of 2-4 mg buprenorphine/naloxone sublingually once mild withdrawal is confirmed 1
• Reassess withdrawal symptoms 30 minutes after first dose using the same validated scale 1
• If tolerated and withdrawal persists, give another 2-4 mg dose 1
• Target Day 1 total: 8 mg (range 4-8 mg depending on tolerance) 1

Dose Titration

• Target maintenance dose is 16 mg daily, which suppresses illicit opioid use in most patients 1
• Dosing range: 4-24 mg daily, adjusted based on withdrawal symptoms and cravings 1
• Higher doses may be needed during pregnancy (2-4 times daily dosing) with increasing gestational age 1

Alternative Induction: Microdosing Protocol

For patients unable to tolerate the abstinence period (especially those using fentanyl), microdosing allows buprenorphine initiation while continuing other opioids, avoiding precipitated withdrawal entirely. 2, 3

7-Day Microdosing Schedule

• Day 1: 0.5 mg once daily 2
• Day 2: 0.5 mg twice daily 2
• Day 3: 1 mg twice daily 2
• Day 4: 2 mg twice daily 2
• Day 5: 3 mg twice daily 2
• Day 6: 4 mg twice daily 2
• Day 7: 12 mg once daily, discontinue all other opioids 2
• Subsequently titrate to 12-32 mg daily as needed 2

This approach has shown success in patients using illicit fentanyl, prescribed methadone, or slow-release morphine without precipitated withdrawal 2, 3

Transition to Long-Acting Injectable Formulations

Patients must be stabilized on 8-24 mg daily sublingual/buccal buprenorphine for minimum 7 consecutive days before transitioning to monthly injectable buprenorphine (Sublocade). 4

Injectable Protocol

• First two monthly doses: 300 mg subcutaneous injection 4
• Maintenance doses: 100 mg monthly thereafter 4
• Combine with behavioral therapies for optimal outcomes 4
• Do not attempt removal of depot injection due to risks of surgical complications, infection, and tissue damage 4

Critical Drug Interactions and Contraindications

• Concomitant use with QT-prolonging agents is contraindicated 1, 4
• Risk of serotonin syndrome when combined with serotonergic agents 1
• Risk of paralytic ileus with anticholinergic medications 1, 4
• Benzodiazepine co-use: While methadone may be preferred with concurrent benzodiazepine use, buprenorphine should not be withheld if it's the only accessible option—use careful medication management 1

Special Populations

Pregnancy

• Continue buprenorphine/naloxone combination if already prescribed—theoretical concerns about naloxone precipitating fetal withdrawal are not supported by evidence 1
• Buprenorphine monotherapy (Subutex) is no longer preferentially recommended over combination therapy (Suboxone) in pregnancy 1
• Buprenorphine results in less severe neonatal opioid withdrawal syndrome, shorter treatment duration, and shorter hospital stays compared to methadone 1
• May require higher and more frequent dosing (2-4 times daily) as pregnancy progresses 1

Perioperative Management

• Decision to continue or hold should reflect: prescribed daily dose, indication (pain vs dependency), relapse risk, and expected postoperative pain level 1
• Multiple drug interactions possible during anesthesia 1
• Coordinate closely with anesthesiology regarding timing and dosing 1

Common Pitfalls to Avoid

• Never initiate standard buprenorphine without confirmed withdrawal symptoms—this is the most common cause of precipitated withdrawal 1
• Do not use oral naloxone for overdose reversal (it's inactivated); use intranasal, subcutaneous, intramuscular, or intravenous routes 1
• Switching from methadone to buprenorphine is challenging and requires close monitoring due to withdrawal risk; switching from buprenorphine to methadone can be done immediately if no sedation present 1
• For patients on naltrexone: hold intramuscular formulation 24-30 days, oral formulation 3-4 days before buprenorphine initiation 1