What is the recommended treatment for brown‑sugar (heroin) withdrawal in an adult patient without contraindications?

Treatment of Brown Sugar (Heroin) Withdrawal

Buprenorphine is the first-line treatment for brown sugar (heroin) withdrawal, initiated at 4–8 mg sublingual when moderate withdrawal symptoms appear (COWS score >8), with a target maintenance dose of 16 mg daily. 1

Pre-Induction Assessment

Before starting buprenorphine, verify the following critical timing requirements to prevent precipitated withdrawal:

• Wait at least 12 hours since the last heroin use before administering the first buprenorphine dose 1, 2
• Confirm the patient is in moderate to severe withdrawal using the Clinical Opiate Withdrawal Scale (COWS score >8) before giving any buprenorphine 1
• A COWS score of 5–12 indicates mild withdrawal (defer treatment), 13–24 indicates moderate withdrawal (safe to initiate), and >24 indicates severe withdrawal 1

Common pitfall: Administering buprenorphine too early—before 12 hours or when COWS <8—will precipitate severe withdrawal because buprenorphine's high receptor affinity displaces residual heroin and triggers acute symptoms. 1

Day 1 Induction Protocol

• Give an initial dose of 4–8 mg sublingual buprenorphine based on withdrawal severity 1, 2
• Reassess after 30–60 minutes; if withdrawal persists, administer additional 2–4 mg doses at 2-hour intervals 1
• Target a total Day 1 dose of approximately 8 mg (range 4–8 mg depending on individual response) 1, 2

Maintenance Dosing (Day 2 Onward)

• Standard maintenance dose is 16 mg sublingual daily, which occupies ~95% of mu-opioid receptors and creates a ceiling effect for both therapeutic benefit and respiratory depression 1
• The effective dose range is 4–24 mg daily; most patients stabilize at 16 mg 1, 2
• Once-daily dosing is preferred; twice-daily dosing (e.g., 8 mg BID) is acceptable but increases respiratory risk when combined with benzodiazepines 1

Critical safety note: The 2023 elimination of the X-waiver requirement means any DEA-licensed provider can now prescribe buprenorphine for opioid use disorder. 1

Second-Line Treatment: Alpha-2 Adrenergic Agonists

When buprenorphine is contraindicated, unavailable, or declined by the patient, use alpha-2 agonists as second-line agents—but recognize they are significantly less effective:

• Lofexidine (FDA-approved): 0.72 mg four times daily (2.88 mg total daily dose) for 5–7 days 3, 4
• Clonidine (off-label): 0.1–0.2 mg every 6–8 hours, titrated based on withdrawal symptoms and blood pressure 3, 5

Evidence of inferiority: Buprenorphine produces lower average withdrawal scores and higher treatment completion rates than clonidine or lofexidine, with a number needed to treat of 4 (meaning one additional patient completes treatment for every four treated with buprenorphine versus alpha-2 agonists). 1, 3

Lofexidine is preferred over clonidine in outpatient settings because it causes less hypotension while maintaining similar efficacy for withdrawal symptom control. 3, 4

Adjunctive Symptom Management

Regardless of whether buprenorphine or alpha-2 agonists are used, add symptom-specific medications to improve comfort and treatment retention:

• Nausea/vomiting: Promethazine or ondansetron 1, 6
• Diarrhea: Loperamide 2–4 mg as needed 1, 6
• Anxiety/muscle cramps: Benzodiazepines (e.g., lorazepam), but monitor closely for respiratory depression when combined with buprenorphine (FDA black-box warning) 1
• Insomnia: Trazodone 50–100 mg at bedtime or gabapentin 300–600 mg three times daily 1

Management of Precipitated Withdrawal

If buprenorphine precipitates withdrawal (due to premature administration):

• Give MORE buprenorphine (not less) as the primary treatment—this is counterintuitive but pharmacologically correct, as additional buprenorphine re-establishes adequate receptor occupancy 1
• Add adjunctive symptomatic therapies: clonidine for autonomic symptoms, antiemetics for nausea, benzodiazepines for anxiety, and loperamide for diarrhea 1

Discharge Planning & Long-Term Treatment

• Prescribe buprenorphine/naloxone 16 mg sublingual daily for 3–7 days or until the first follow-up appointment 1
• Provide a take-home naloxone kit and overdose-prevention education, as patients become more sensitive to opioids after withdrawal and face increased overdose risk if they relapse 1, 6
• Offer hepatitis C and HIV screening and consider reproductive health counseling 1

Duration of treatment: There is no maximum recommended duration of buprenorphine maintenance—patients may require treatment indefinitely, as discontinuation precipitates withdrawal and dramatically increases relapse risk to more dangerous opioids. 1, 2 Maintenance therapy is more effective than short-term detoxification in preventing relapse among patients with opioid use disorder. 1

Common Pitfalls to Avoid

• Never initiate buprenorphine when COWS <8—this precipitates severe withdrawal 1
• Never discharge patients on alpha-2 agonists alone without a definitive addiction-treatment plan, as these agents only address acute withdrawal and do not prevent relapse 3
• Never prescribe discharge doses below 16 mg daily—this often results in persistent withdrawal symptoms and treatment failure 1
• Never abruptly discontinue buprenorphine—taper slowly if discontinuation is desired, as abrupt cessation precipitates withdrawal and increases relapse risk 1