A patient who has been off Suboxone (buprenorphine/naloxone) 8 mg/2 mg daily for one month—what starting dose should be used when restarting therapy?

Restarting Suboxone After One Month Off: Starting Dose Recommendation

Start with 4 mg sublingual on Day 1, then advance to 16 mg on Day 2, which becomes the standard maintenance dose for most patients. 1

Critical Pre-Induction Requirements

Before administering any buprenorphine, you must verify the patient is in moderate to severe withdrawal (COWS score ≥8) to avoid precipitating severe withdrawal symptoms. 1, 2

Timing since last opioid use matters:

• If the patient used short-acting opioids (heroin, fentanyl, immediate-release pills) during the month off Suboxone, wait >12 hours since last use 1, 2
• If they used extended-release formulations, wait >24 hours 1, 2
• If they were on methadone, wait >72 hours and strongly consider continuing methadone instead 1

Day 1 Induction Protocol

Initial dose: Give 4–8 mg sublingual when COWS ≥8, then reassess after 30–60 minutes. 1, 2

Titration on Day 1:

• If withdrawal persists after the initial dose, provide additional 2–4 mg every 2 hours as needed 1
• Target a total Day 1 dose of approximately 8 mg (range 4–8 mg) 1, 2
• The FDA label notes that gradual induction over several days led to high dropout rates, so achieving an adequate dose rapidly is preferred 2

Day 2 and Maintenance Dosing

Day 2: Advance to 16 mg sublingual daily 1, 2

Standard maintenance: 16 mg sublingual daily is the recommended target dose, which occupies approximately 95% of mu-opioid receptors and creates a ceiling effect for both therapeutic benefit and respiratory depression. 1

Dose range: The maintenance range is 4–24 mg daily, adjusted in 2 mg or 4 mg increments to suppress withdrawal and hold the patient in treatment. 2 Doses higher than 24 mg have not demonstrated clinical advantage. 2

Key Differences from Initial Treatment

This patient is NOT opioid-naive after only one month off. Even though they discontinued Suboxone, their opioid receptor physiology may not have fully reset, and they likely retain some degree of tolerance. However, you should not assume they can restart at their previous 8 mg dose immediately—standard induction protocols still apply because:

• Buprenorphine's high receptor affinity can displace any residual or recently used full agonist opioids and precipitate withdrawal if given too early 3
• The patient's tolerance may have decreased during the month off, increasing sensitivity to both therapeutic effects and adverse effects 3

Management of Precipitated Withdrawal

If precipitated withdrawal occurs despite proper timing:

• Give MORE buprenorphine (not less) as the primary treatment 1
• Add adjunctive medications: clonidine 0.1–0.2 mg every 6–8 hours for autonomic symptoms, antiemetics (promethazine or ondansetron) for nausea, benzodiazepines for anxiety/muscle cramps, and loperamide for diarrhea 3, 1

Duration of Treatment

There is no maximum recommended duration of maintenance treatment—patients may require treatment indefinitely and should continue as long as they are benefiting. 1, 2 Discontinuing buprenorphine precipitates withdrawal and dramatically increases relapse risk to more dangerous opioids. 1

Common Pitfalls to Avoid

• Do not restart at the previous 8 mg dose on Day 1 without following proper induction protocol—start lower (4 mg) and titrate 1, 2
• Do not give buprenorphine when COWS <8—this precipitates severe withdrawal 1
• Do not discharge on doses below 16 mg daily—this often results in persistent withdrawal and treatment failure 1
• Do not assume the patient is opioid-free during the month off—verify last opioid use and wait appropriate intervals 1, 2