Suboxone Dispensing Practices
Suboxone (buprenorphine/naloxone) is typically dispensed as a 30-day supply with refills allowed, unlike methadone which requires daily clinic visits for most patients. This office-based prescribing model makes buprenorphine treatment more accessible and acceptable to patients who would not attend traditional opioid maintenance clinics 1.
Standard Dispensing Protocol
Initial Prescription
- Prescribers can write prescriptions for Suboxone that patients fill at retail pharmacies, distinguishing it from methadone's clinic-based dispensing model 1
- The typical therapeutic dose range is 8-16 mg daily, with a target of 16 mg for most patients 2
- Suboxone contains buprenorphine and naloxone in a 4:1 ratio (e.g., 8 mg buprenorphine/2 mg naloxone) 3, 4
Supply Duration and Refills
- Standard practice allows for 30-day supplies with refills, enabling less frequent clinic visits compared to methadone programs 2
- Less frequent dispensing (e.g., thrice weekly) does not compromise efficacy and can improve patient satisfaction 3
- For patients with stable opioid use disorder in remission who demonstrate good adherence, weekly "pickups" or "take homes" may be appropriate 5
Formulation Selection
Suboxone (Buprenorphine/Naloxone) - Preferred for Most Patients
- The American Academy of Family Physicians recommends buprenorphine/naloxone as the preferred formulation due to safety features that prevent misuse by crushing and injecting 2
- The naloxone component has relatively low sublingual bioavailability and exerts no clinically significant effect when taken as prescribed 3, 6
- When parenterally administered, naloxone causes withdrawal effects in opioid-dependent patients, reducing abuse potential 3
Subutex (Buprenorphine Alone) - Special Circumstances
- May be preferred for pregnancy, documented naloxone allergy, or patients with severe chronic pain requiring divided doses 2
- Subutex is specifically recommended for pregnant women to avoid naloxone exposure 1
Dosing Schedules
Standard Maintenance Dosing
- Once-daily dosing is standard for opioid use disorder maintenance 2
- Sublingual tablets typically disintegrate in 6-12 minutes 4
- Plasma concentrations decline bi-exponentially with a terminal half-life of approximately 26 hours (range 9-69 hours) 4
Divided Dosing for Pain Management
- For chronic pain management, buprenorphine can be prescribed off-label in split doses (every 6-8 hours) 5, 2
- Dosing ranges of 4-16 mg divided into 8-hour doses have shown benefit in patients with chronic non-cancer pain 5
Critical Dispensing Considerations
Preventing Precipitated Withdrawal
- Suboxone should only be dispensed to patients in active opioid withdrawal 2, 7
- Required waiting periods before first dose: short-acting opioids >12 hours, extended-release formulations >24 hours, methadone >72 hours 2, 7
- Use the Clinical Opiate Withdrawal Scale (COWS) to confirm withdrawal severity before dispensing 2, 7
Monitoring Requirements
- Regular urine drug testing to assess for continued illicit opioid use 2
- Hepatitis C and HIV screening as part of comprehensive care 2, 7
- Assess for opioid use disorder using DSM-5 criteria during follow-up visits 2
Common Pitfall to Avoid
Never dispense or administer buprenorphine while patients are still under the influence of full opioid agonists, as this will precipitate severe withdrawal due to buprenorphine's high receptor affinity displacing other opioids 2, 7. This is the most critical safety consideration in Suboxone dispensing.