What are the typical dosages for Suboxone (buprenorphine) sublingual films in the treatment of opioid addiction?

Suboxone Sublingual Film Dosages

For opioid use disorder treatment, initiate Suboxone with 4-8 mg sublingual on Day 1 (given only when moderate withdrawal symptoms appear), increase to 16 mg on Day 2, then maintain at 16 mg daily as the target dose, with a typical maintenance range of 4-24 mg daily. 1

Induction Phase Dosing

Timing Requirements Before First Dose

• Short-acting opioids (heroin, morphine IR): Wait at least 4 hours, but preferably >12 hours after last use 1, 2
• Extended-release formulations (OxyContin): Wait >24 hours after last use 2
• Methadone maintenance: Wait >72 hours after last use (consider continuing methadone instead) 2, 1

Initial Dosing Strategy

• Day 1: Administer 8 mg sublingual when objective signs of moderate opioid withdrawal appear 1
• Day 2: Increase to 16 mg sublingual 1
• Day 3 onward: Continue 16 mg daily as target maintenance dose 1

Withdrawal Severity-Based Dosing (Emergency Department Protocol)

• Mild withdrawal (COWS <8): No buprenorphine indicated; reassess in 1-2 hours 2
• Moderate to severe withdrawal (COWS ≥8): Give 4-8 mg sublingual based on severity; reassess after 30-60 minutes 2

Maintenance Phase Dosing

Target Maintenance Dose

• Recommended target: 16 mg sublingual once daily 1
• Typical range: 4-24 mg buprenorphine per day 1
• Maximum studied dose: 24 mg daily (higher doses show no additional clinical advantage) 1

Dose Adjustments

• Adjust in increments/decrements of 2 mg or 4 mg to maintain treatment retention and suppress withdrawal symptoms 1
• Titrate to clinical effectiveness as rapidly as possible to reduce early dropout rates 1

Administration Technique

Critical Instructions

• Place tablets/films under the tongue until completely dissolved 1
• Do not cut, chew, or swallow the medication 1
• Avoid eating or drinking until fully dissolved 1
• For doses requiring >2 tablets: place all at once if possible, or place 2 at a time sequentially under tongue 1

Bioavailability Considerations

• Sublingual absorption is rapid with peak plasma concentration at 1 hour 3
• Buprenorphine has very low oral bioavailability due to extensive first-pass metabolism 4
• Consistent administration technique is essential for stable bioavailability 1

Prescribing for Unsupervised Administration

Emergency Department Discharge Protocol

• X-waivered prescribers: Prescribe 16 mg sublingual daily for 3-7 days until follow-up 2
• Non-X-waivered prescribers: Patients may return for up to 3 consecutive days for interim treatment 2
• Sample 3-day prescription: Buprenorphine/naloxone 8 mg/2 mg sublingual film, take 2 films once daily in AM, dispense #6, no refills 2

Supervision Recommendations

• Begin with supervised administration, progressing to unsupervised as clinical stability permits 1
• See patients at reasonable intervals (ideally at least weekly during first month) 1
• Avoid multiple refills early in treatment or without appropriate follow-up visits 1

Pharmacokinetic Considerations

Dose-Response Relationship

• Plasma buprenorphine concentrations increase with dose but not proportionally—the 32 mg dose produces only 54% of the dose-adjusted exposure compared to 4 mg 5
• Most subjective and physiological effects plateau at higher doses due to partial agonist properties 5
• Large inter-subject variability exists in plasma levels and clinical response 3

Naloxone Component

• The 4:1 buprenorphine:naloxone ratio is designed to deter injection abuse 6
• Naloxone is poorly absorbed sublingually and does not affect buprenorphine's efficacy when taken as prescribed 3, 7
• Intramuscular injection precipitates withdrawal in opioid-dependent persons, reducing abuse potential 7

Duration of Treatment

• No maximum duration for maintenance treatment 1
• Patients may require treatment indefinitely and should continue as long as they are benefiting 1
• Treatment effectiveness is comparable to methadone for opioid dependence 6

Critical Pitfalls to Avoid

• Never administer before withdrawal symptoms appear—buprenorphine's high receptor affinity can precipitate severe withdrawal in patients with recent full agonist opioid use 1, 2
• Methadone patients are at highest risk for precipitated withdrawal, especially those on >30 mg daily 1
• Do not confuse formulations: Sublingual films/tablets are for opioid use disorder; transdermal patches are only for chronic pain management 8