What is the recommended management for a patient with opioid use disorder since starting Suboxone (buprenorphine/naloxone) treatment?

Management of Opioid Use Disorder on Suboxone

Continue Suboxone maintenance therapy indefinitely at a target dose of 16 mg daily (range 8-24 mg), combined with behavioral therapy, as discontinuation significantly increases relapse and overdose risk. 1, 2

Ongoing Maintenance Protocol

Dosing Strategy

• Maintain patients on 16 mg daily as the standard therapeutic dose, with an FDA-approved range of 8-24 mg based on individual response 1, 2
• Higher or more frequent dosing (2-4 times daily) may be required during pregnancy due to altered pharmacokinetics 3
• For chronic pain management in patients on Suboxone for OUD, consider switching to transdermal buprenorphine alone (without naloxone) as it bypasses first-pass hepatic metabolism and may provide superior analgesia 3

Monitoring Requirements

• Visit frequency should be at least weekly during the first month, then can be reduced to monthly once stable dosing is achieved and urine drug screens show no illicit use 4
• Perform regular urine drug testing at each visit to assess for illicit opioid use and medication compliance 2, 4
• Screen for hepatitis C and HIV periodically 2, 5
• Assess for medication toxicity, adverse effects, and responsible medication handling at each visit 4
• Verify abstinence from problematic alcohol and benzodiazepine use 4

Behavioral Health Integration

• Suboxone must be combined with behavioral therapies—never prescribed as monotherapy—as this combination reduces opioid misuse, increases treatment retention, and prevents relapse more effectively than medication alone 1, 2
• Coordinate care with behavioral health providers and ensure patients engage in recovery-oriented activities and psychosocial interventions 4

Managing Treatment Challenges

Continued Illicit Opioid Use

• If urine drug screens show ongoing illicit opioid use in the first few months, increase visit frequency and intensify behavioral therapy engagement rather than immediately discontinuing medication 6
• For patients who continue to misuse, abuse, or divert Suboxone or other opioids despite intensified treatment, refer to more intensive and structured treatment settings or addiction specialists 4

Acute Pain Management

• When acute pain occurs, increase the buprenorphine dose first, as higher doses provide additional analgesia without the respiratory depression ceiling effect seen with full agonists 3
• If maximum buprenorphine dosing is insufficient, add high-potency opioids such as fentanyl or hydromorphone, as buprenorphine does not occupy all opioid receptors 3
• Consider switching from sublingual buprenorphine/naloxone to transdermal buprenorphine for better chronic pain control 3

Mental Health Screening

• Screen all patients 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?" 3
• Use the PHQ-9 for formal depression diagnosis; refer for psychiatric evaluation if score ≥10 3
• Screen for neurocognitive disorders before and during long-term opioid therapy 3

Duration of Treatment

Encourage indefinite continuation of Suboxone therapy, as discontinuation increases relapse risk and overdose mortality 4, 7, 8

• Methadone and buprenorphine reduce mortality, opioid use, and HIV/hepatitis C transmission while increasing treatment retention 7
• Longer treatment duration allows restoration of social connections and is associated with better outcomes 8
• If discontinuation is pursued, taper slowly using divided doses combined with symptomatic management, though evidence shows shorter tapers may be as effective as longer tapers for preventing relapse 5

Harm Reduction Measures

• Provide naloxone kits for overdose prevention, as patients face increased overdose risk if they relapse to illicit opioid use, particularly after treatment discontinuation 5
• Advise patients of the high potential to relapse to illicit drug use following discontinuation of medication-assisted treatment 4

Special Populations

Pregnancy

• Continue buprenorphine during pregnancy, but switch from buprenorphine/naloxone (Suboxone) to buprenorphine monotherapy (Subutex) if initiating treatment, though women already stable on Suboxone can continue it 3
• Buprenorphine during pregnancy results in less severe neonatal opioid withdrawal syndrome, shorter treatment duration, and shorter hospital stays compared to methadone 3
• Establish plans for postpartum continuation of buprenorphine during pregnancy 3

Adolescents

• Suboxone is FDA-approved for patients 16 years and older 1, 2
• Buprenorphine is particularly important for adolescents as federal regulations generally prohibit methadone programs from admitting patients under 18 1, 2