What are the guidelines for using buprenorphine (Opioid Partial Agonist) for follow-up (FU) treatment of Opioid Use Disorder (OUD) in patients?

Buprenorphine Follow-Up Guidelines for Opioid Use Disorder

Core Follow-Up Recommendations

Patients with OUD should continue buprenorphine indefinitely as maintenance therapy, with sublingual formulations dosed at 8-24 mg daily combined with counseling and psychosocial support. 1

• Buprenorphine treatment must be combined with counseling and psychosocial support—medication alone is insufficient for optimal outcomes. 1
• Target maintenance dose is typically 16 mg sublingual daily for most patients, though the effective range is 8-24 mg daily. 2
• After stabilization on sublingual buprenorphine (minimum 7 consecutive days at 8-24 mg daily), consider transition to long-acting injectable formulations (Sublocade): two initial 300 mg monthly subcutaneous injections, followed by 100 mg monthly maintenance doses. 1, 3

Dosing Optimization During Follow-Up

• Higher doses (up to 32 mg daily) improve outcomes even when patients continue using opioids, including reduced opioid use frequency (1.58 uses/week at 24 mg vs 1.15 uses/week at 32 mg), decreased physiologic triggers for use (38.2% at 24 mg vs 7.0% at 32 mg), and better retention in treatment (78.7% vs 50.0%). 4
• The FDA-approved maximum is 24 mg daily, but doses up to 32 mg have demonstrated safety and effectiveness for patients with persistent opioid use or cravings. 4
• For patients with comorbid chronic pain, divide the daily buprenorphine dose into every 6-8 hour dosing to leverage analgesic properties. 1

Duration of Treatment

Buprenorphine should be continued indefinitely for OUD—there is no predetermined endpoint for discontinuation. 5

• Most patients who taper from buprenorphine relapse to more dangerous opioids. 2
• The determination that treatment should not have been initiated is not equivalent to a decision that it should be stopped. 2
• Buprenorphine for OUD should not be reduced or discontinued in attempts to comply with analgesia guidelines. 2

Monitoring and Safety During Follow-Up

• Offer naloxone for overdose prevention to all patients with OUD at every follow-up visit. 1
• Monitor for respiratory depression risk, particularly in patients with compromised respiratory function (COPD, cor pulmonale, decreased respiratory reserve). 1
• Assess for QT-prolonging medications at each visit, as concomitant use with buprenorphine is contraindicated. 1
• Screen for hepatitis C and HIV, and provide reproductive health counseling. 2

Managing Continued Opioid Use During Follow-Up

Relapse or continued opioid use during buprenorphine treatment does not indicate treatment failure and should not prompt discontinuation. 5

• Higher buprenorphine dosing (up to 32 mg daily) improves outcomes even in the absence of complete abstinence. 4
• Consider dose optimization (increasing to 24-32 mg daily) before concluding treatment is ineffective. 4
• For patients with persistent opioid use despite adequate buprenorphine dosing, reassess for undertreated pain, psychiatric comorbidities, or psychosocial stressors rather than discontinuing medication. 2

Counseling and Psychosocial Support Requirements

• Counseling must be provided alongside medication, though the intensity and frequency should be tailored to patient needs and availability. 1
• Lack of access to counseling should not be a barrier to continuing buprenorphine treatment, as medication alone is superior to no treatment. 5
• Medication for addiction treatment (MAT) combining buprenorphine with counseling and behavioral therapies provides a "whole-patient" approach and has demonstrated effectiveness in saving lives. 2

Special Populations in Follow-Up Care

Pregnant Patients

• Continue buprenorphine throughout pregnancy—it improves maternal outcomes and is the standard of care. 1

Patients Requiring Surgery

• Continue buprenorphine at baseline dose throughout the perioperative period—it is rarely appropriate to reduce or discontinue regardless of indication or formulation. 2, 1
• Maintain buprenorphine to prevent withdrawal and preserve addiction treatment stability. 1
• Use multimodal analgesia and regional techniques for postoperative pain management. 2
• Discharge patients on at least some dose of buprenorphine to maintain stability of OUD treatment. 2

Patients on Benzodiazepines

• The combination of buprenorphine and benzodiazepines should be reduced (or the benzodiazepine reduced or discontinued) unless the combination has shown benefit and alternative treatments are not beneficial or feasible. 2
• Reserve concomitant prescribing for patients where alternative treatment options are inadequate, using the minimum required dosages and durations. 6

Common Pitfalls to Avoid

• Do not discontinue buprenorphine due to continued opioid use—this represents a need for dose optimization or additional support, not treatment failure. 4, 5
• Do not taper buprenorphine to comply with opioid prescribing guidelines—buprenorphine for OUD is addiction treatment, not chronic pain management subject to those restrictions. 2
• Do not require complete abstinence from all substances as a condition for continuing treatment—harm reduction is the goal, and buprenorphine reduces overdose risk even with continued use. 5
• Do not stop buprenorphine before surgery—continuation prevents withdrawal and maintains addiction treatment stability while allowing effective pain management with adjunctive strategies. 2, 1

Drug Interactions Requiring Monitoring

• CYP3A4 inhibitors (macrolide antibiotics, azole antifungals, protease inhibitors) can increase buprenorphine levels—consider dose reduction if sedation or respiratory depression occurs. 6
• CYP3A4 inducers (rifampin, carbamazepine, phenytoin) can decrease buprenorphine levels—consider dose increase if withdrawal symptoms or increased cravings emerge. 6
• Serotonergic drugs (SSRIs, SNRIs, TCAs, MAOIs) carry risk of serotonin syndrome—monitor for agitation, confusion, rapid heart rate, high blood pressure, dilated pupils, muscle rigidity, and hyperthermia. 6

Transition to Long-Acting Injectable Formulations

• After minimum 7 consecutive days of stability on 8-24 mg daily sublingual buprenorphine, initiate Sublocade with two 300 mg monthly injections, then 100 mg monthly maintenance. 1, 3
• Patients must demonstrate tolerance to buprenorphine before first injection to minimize precipitated withdrawal risk. 1, 3
• Long-acting formulations may improve adherence and decrease diversion risk. 7