Suboxone Micro-Induction: Recommended Dosing Strategy
Buprenorphine micro-induction is a safe and effective method that allows initiation of buprenorphine while continuing full opioid agonists (including methadone or illicit fentanyl), avoiding the traditional requirement for moderate withdrawal and minimizing precipitated withdrawal risk. 1, 2
Core Principles of Micro-Induction
The fundamental approach involves starting at very low buprenorphine doses and gradually titrating upward over several days, taking advantage of slow displacement of full opioid agonists from mu-opioid receptors. 1 This method is particularly valuable for patients with complex substance use patterns, including concurrent benzodiazepine use, cocaine use, or substance-induced psychosis, as it eliminates the barrier of requiring opioid abstinence before induction. 1, 2
Specific Dosing Protocol
The most commonly described and successful regimen follows a 7-day schedule: 2, 3
- Day 1: 0.5 mg sublingual buprenorphine/naloxone 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, with discontinuation of all full opioid agonists 2
- Subsequent days: Titrate to maintenance dose of 12-32 mg daily 2
The average rate of increase to reach 8 mg is approximately 1.36 mg/day, though this can be slowed to 1.17 mg/day if any signs of precipitated withdrawal emerge. 4
Critical Management Considerations
Continue all full opioid agonists (prescribed methadone, prescribed opioids, or illicit fentanyl) throughout the induction period until Day 7. 1, 2, 3 This is the defining feature that distinguishes micro-induction from traditional methods and is essential for success. Patients should be explicitly instructed not to stop their current opioid use during the first 6 days. 1
Pause or delay buprenorphine dose escalation immediately if any withdrawal symptoms occur. 1 If withdrawal emerges, hold at the current buprenorphine dose for 24-48 hours before attempting further increases, or reduce back to the previous tolerated dose. 1
Special Considerations for Complex Substance Use
For patients with concurrent benzodiazepine use, do not attempt to taper benzodiazepines during buprenorphine micro-induction. 5 The CDC guideline emphasizes that when patients are on both medications, if tapering is necessary for safety, opioids should be tapered first because benzodiazepine withdrawal carries greater risks including seizures and delirium tremens. 5 However, during the micro-induction phase, maintain stability on both medications and address benzodiazepine reduction only after successful buprenorphine stabilization. 5
Cocaine use and substance-induced psychosis history do not contraindicate micro-induction. 5 These conditions should be monitored and managed concurrently, but the micro-induction protocol itself does not require modification. 5
Monitoring Requirements
Daily or every-other-day contact during the first week is essential. 1, 6 This can be accomplished through in-person visits, telehealth, or assertive outreach models. 6 The frequent contact serves to:
- Assess for any signs of precipitated withdrawal 1
- Verify medication adherence 1
- Provide reassurance and support 1
- Adjust the protocol if needed 1
Screen for and aggressively treat emerging depression, anxiety, and insomnia during induction. 7 These symptoms commonly emerge during any buprenorphine transition and predict treatment discontinuation. 7
Clinical Setting Considerations
Micro-induction can be successfully performed in outpatient community-based settings, including methadone maintenance programs. 3 Hospital-based initiation may be preferred for patients with:
- High-dose methadone (>60 mg daily) 3
- Unstable housing or limited ability to attend frequent appointments 6
- Severe psychiatric comorbidity requiring closer monitoring 5
- Concurrent medical complications 5
Common Pitfalls to Avoid
Do not require patients to stop their full opioid agonist before starting micro-induction - this defeats the entire purpose of the method and reverts to traditional induction barriers. 1, 2
Do not advance the dose schedule rigidly if the patient reports any discomfort - flexibility and patient-driven pacing are critical for success. 1
Do not fail to communicate clearly about the plan - patients must understand they will continue their current opioid use while adding buprenorphine, and that full discontinuation of other opioids occurs only on Day 7. 1
Do not use this method without capacity for frequent monitoring - the systematic review found that all successful cases involved close follow-up. 4
Evidence Quality and Limitations
The current evidence base consists primarily of case series and reports (n=57 patients across 20 studies), with all studies rated as low quality due to selection bias and inconsistent reporting. 4 However, 100% of patients in published reports achieved desired maintenance doses without precipitated withdrawal. 4 Given the safety profile of buprenorphine and the life-saving potential in the context of fentanyl-contaminated drug supply, this approach is justified despite limited high-quality evidence. 1, 6
Pharmacotherapy Framework
This micro-induction approach aligns with FDA-approved use of buprenorphine/naloxone for opioid use disorder treatment. 8 The CDC guideline strongly recommends offering medication-assisted treatment (buprenorphine or methadone) combined with behavioral therapies for patients with opioid use disorder, as this is more effective than behavioral interventions alone. 5 The micro-induction method expands access to this evidence-based treatment by removing traditional barriers. 1