What is the recommended approach for initiating Suboxone (buprenorphine) treatment in a patient with a history of opioid use disorder, currently experiencing opioid cravings, who has not used opioids for six months?

Initiating Suboxone in a Patient with Six Months of Abstinence

Yes, you can and should initiate Suboxone for this patient experiencing opioid cravings, as the presence of cravings indicates ongoing opioid use disorder regardless of recent abstinence, and buprenorphine maintenance therapy reduces relapse risk and improves long-term outcomes. 1, 2

Clinical Rationale for Treatment

• Opioid use disorder is a chronic, relapsing condition that persists even during periods of abstinence, and cravings represent a core symptom of the disorder. 3
• The DSM-5 defines opioid use disorder as a problematic pattern causing clinically significant impairment with at least two diagnostic criteria present within a year—cravings alone constitute one of these criteria. 2
• Medication-assisted treatment with buprenorphine combined with behavioral therapies reduces illicit opioid use, prevents relapse, and improves patient outcomes more effectively than behavioral therapy alone. 1, 2
• Patients who discontinue treatment face substantially increased overdose risk if they return to illicit opioid use, making proactive treatment of cravings a mortality-reduction strategy. 4

Critical Difference: This is NOT Standard Induction

The key distinction here is that this patient is NOT in active withdrawal and has not used opioids recently, so you will NOT follow the standard withdrawal-based induction protocol. 5, 1

Standard Protocol Does NOT Apply:

• Traditional buprenorphine induction requires patients to be in active opioid withdrawal (COWS >8) with specific time intervals since last use: >12 hours for short-acting opioids, >24 hours for extended-release formulations, or >72 hours for methadone. 5, 1
• This requirement exists to prevent precipitated withdrawal when transitioning FROM full agonist opioids TO buprenorphine. 5, 1, 4

Your Patient's Situation:

• After six months of abstinence, there is no risk of precipitated withdrawal because no full agonist opioids are occupying the mu-opioid receptors. 1, 4
• You can initiate buprenorphine immediately without waiting for withdrawal symptoms to develop. 1

Recommended Initiation Approach

Starting Dose and Titration:

• Begin with buprenorphine/naloxone 4-8 mg sublingual on day one, then titrate to the target maintenance dose of 16 mg daily within the first few days. 5, 1, 2
• The therapeutic dose range is 8-16 mg daily, with 16 mg daily as the target for most patients. 1, 2
• Recent evidence suggests that some patients benefit from doses up to 32 mg daily, particularly those with persistent opioid use or cravings at lower doses. 6

Formulation Selection:

• Prescribe buprenorphine/naloxone (Suboxone) rather than buprenorphine alone (Subutex) as the naloxone component reduces misuse potential by preventing effective use via crushing and injection. 1, 2

Essential Treatment Components

Comprehensive Assessment Before Starting:

• Screen for depression using the two-question screen: "During the past 2 weeks have you often been bothered by feeling down, depressed, or hopeless?" and "During the past 2 weeks have you been bothered by little interest or pleasure in doing things?" 5
• Review baseline mental health status for modifiable factors including self-esteem, coping skills, recent major loss, mood disorders, and history of serious mental illness or suicidal ideation. 5
• Confirm the diagnosis of opioid use disorder using DSM-5 criteria during your initial assessment. 2

Mandatory Concurrent Interventions:

• Buprenorphine must be combined with counseling and behavioral therapies—medication alone has poor long-term outcomes. 1, 2, 4
• Provide overdose prevention education and a take-home naloxone kit, as patients remain at risk for overdose if they relapse to illicit opioid use. 5, 4
• Offer hepatitis C and HIV screening as part of comprehensive care. 5, 1, 4

Monitoring Protocol

Initial Follow-up:

• Reassess the patient within 1-4 weeks of starting buprenorphine to evaluate benefits (reduction in cravings, functional improvement) and harms (side effects such as constipation, headache, drowsiness). 5
• Use validated tools such as the three-item PEG Assessment Scale (Pain average, interference with Enjoyment of life, and interference with General activity) to assess functional outcomes. 5

Ongoing Monitoring:

• Conduct regular urine drug testing to assess for illicit opioid use and medication adherence. 1, 2
• Reassess using DSM-5 criteria at follow-up visits to monitor treatment response. 2
• Evaluate benefits and harms every 3 months or more frequently as clinically indicated. 5

Common Pitfalls to Avoid

• Do not withhold buprenorphine simply because the patient is currently abstinent—cravings indicate active disease requiring treatment, and delaying treatment increases relapse and overdose risk. 2, 4, 3
• Do not prescribe buprenorphine alone (Subutex) when buprenorphine/naloxone (Suboxone) is appropriate, as the combination formulation reduces diversion risk. 1, 2
• Do not treat with buprenorphine as monotherapy—the medication must be combined with behavioral interventions for optimal outcomes. 1, 2
• Avoid concomitant use with QT-prolonging agents due to cardiac complication risk. 1

Duration of Treatment

• Longer duration of treatment allows restoration of social connections and is associated with better outcomes. 3
• Opioid use disorder is a chronic condition, and many patients require long-term or indefinite maintenance therapy. 3, 7
• If discontinuation is considered in the future, use a slow taper with symptomatic management, though evidence suggests shorter tapers may be as effective as longer tapers for preventing relapse. 4