What is the recommended initial dose and treatment protocol for initiating Suboxone (buprenorphine/naloxone) in a patient with opioid use disorder?

Initiating Suboxone for Opioid Use Disorder

Administer buprenorphine/naloxone 4-8 mg sublingual only when the patient demonstrates moderate-to-severe opioid withdrawal (COWS score >8), targeting a Day 1 total dose of 8 mg and advancing to 16 mg daily maintenance by Day 2. 1, 2, 3

Pre-Induction Requirements

Before administering the first dose, you must confirm three critical elements to avoid precipitated withdrawal:

Timing Since Last Opioid Use

• Short-acting opioids (heroin, morphine IR, oxycodone IR): Wait minimum 12 hours 1, 4, 3
• Extended-release formulations (OxyContin, MS Contin): Wait minimum 24 hours 1, 4, 3
• Methadone maintenance patients: Wait minimum 72 hours—this is critical as methadone's long half-life creates severe risk for precipitated withdrawal 1, 4, 3

Document Objective Withdrawal Signs

Use the Clinical Opiate Withdrawal Scale (COWS) to assess 11 clinical parameters including pulse rate, sweating, restlessness, pupil size, bone/joint aches, rhinorrhea/lacrimation, GI upset, tremor, yawning, anxiety, and piloerection. 4

Only proceed if COWS score >8 (moderate-to-severe withdrawal). 1, 2, 4 If COWS <8, do not give buprenorphine—reassess in 1-2 hours. 1

Day 1 Induction Protocol

Initial Dosing

• Give 4-8 mg sublingual based on withdrawal severity 1, 2, 4
• Place tablet/film under tongue until completely dissolved (5-10 minutes) 3
• Instruct patient not to eat or drink until fully dissolved 3

Reassessment and Additional Dosing

• Reassess COWS after 30-60 minutes 1, 4
• If withdrawal persists, give additional 2-4 mg doses at 2-hour intervals 4
• Target Day 1 total: 8 mg (range 4-8 mg acceptable) 4, 3

Day 2 and Maintenance

Standard Protocol

• Day 2: Advance to 16 mg daily 4, 3
• Maintenance dose: 16 mg daily for most patients 1, 2, 4, 5, 3
• Dosing range: 4-24 mg daily (higher doses up to 32 mg increasingly necessary in fentanyl era) 2, 3
• Administer as single daily dose 3

Formulation Selection

Prescribe buprenorphine/naloxone (Suboxone) for maintenance, not buprenorphine monotherapy (Subutex), as the naloxone component prevents injection misuse. 5, 3, 6 The naloxone is poorly absorbed sublingually and does not contribute to withdrawal prevention—it only deters IV abuse. 4

Discharge Planning

Prescription Details

For providers (X-waiver no longer required as of 2023): 4

• Prescribe 16 mg sublingual daily for 3-7 days or until follow-up appointment 1, 4
• Sample prescription: "Buprenorphine/naloxone 8 mg/2 mg SL film, Take 2 films once daily in AM, Dispense #6, No Refills" 1

Harm Reduction Measures

Provide at discharge: 1, 4

• Take-home naloxone kit with overdose prevention education
• Hepatitis C and HIV screening
• Reproductive health counseling

Critical Safety Warnings

Precipitated Withdrawal Risk

Buprenorphine's high receptor binding affinity and partial agonist properties will displace full opioid agonists and cause severe precipitated withdrawal if given too early. 1, 2, 4, 3 This is especially dangerous in:

• Methadone patients (requires 72+ hour wait) 1, 4, 3
• Fentanyl users (consider micro-induction protocols as alternative) 4, 7

Managing Precipitated Withdrawal If It Occurs

Give more buprenorphine—this is the primary treatment, as additional buprenorphine will eventually saturate receptors and relieve symptoms. 4 Adjunctive symptomatic management includes:

• Clonidine for autonomic symptoms (tachycardia, hypertension, sweating) 4
• Antiemetics (promethazine, ondansetron) for nausea/vomiting 1, 4
• Benzodiazepines for anxiety and muscle cramps 1, 4
• Loperamide for diarrhea 1, 4

Duration of Treatment

There is no maximum recommended duration—patients may require treatment indefinitely. 4, 3 Never taper or discontinue buprenorphine to comply with opioid dose guidelines, as discontinuation precipitates withdrawal and dramatically increases relapse risk to more dangerous opioids. 4 Buprenorphine has a ceiling effect on respiratory depression, making it safer than full agonists even at high doses. 2, 6

Common Pitfalls to Avoid

• Premature induction: Starting before adequate withdrawal (COWS >8) precipitates severe withdrawal syndrome 2, 4
• Inadequate Day 1 dosing: Gradual induction over several days leads to high dropout rates—achieve adequate dose rapidly 3
• Underdosing maintenance: 16 mg is the target for most patients; don't hesitate to use 24-32 mg in fentanyl era 2, 3
• Ignoring methadone timing: The 72-hour wait for methadone patients is non-negotiable—consider continuing methadone instead 1, 4