What is the safest way to transition a patient taking Percocet (oxycodone/acetaminophen) to Suboxone (buprenorphine‑naloxone)?

Transitioning from Percocet to Suboxone: Evidence-Based Protocol

To safely transition a patient from Percocet (oxycodone/acetaminophen) to Suboxone (buprenorphine-naloxone), you must wait until the patient is in moderate-to-severe opioid withdrawal (COWS score ≥8), typically 12–24 hours after the last Percocet dose, then initiate buprenorphine 4–8 mg sublingually and titrate to a maintenance dose of 16 mg daily. 1

Pre-Transition Assessment

Before initiating the switch, complete the following safety checks:

• Screen for QT-prolonging medications that are contraindicated with buprenorphine 2
• Identify high-risk benzodiazepine co-prescribing (FDA black-box warning for respiratory depression and death when combined with buprenorphine) 2
• Review the state Prescription Drug Monitoring Program (PDMP) for other controlled substances 2
• Assess for opioid use disorder (OUD) using DSM-5 criteria, recognizing that many OUD criteria can occur in chronic pain patients and may yield false-positives 2

Critical Timing Requirements

The most common pitfall is initiating buprenorphine too early, which precipitates severe withdrawal due to buprenorphine's high receptor affinity displacing oxycodone. 1

• Wait >12 hours after the last dose of immediate-release Percocet before considering buprenorphine 1
• If the patient was taking extended-release oxycodone formulations, wait >24 hours 1
• Do not administer buprenorphine until the patient demonstrates moderate-to-severe withdrawal 1

Withdrawal Assessment Using COWS

Use the Clinical Opiate Withdrawal Scale (COWS) to objectively confirm withdrawal status before every buprenorphine dose: 1

• COWS 5–12 = mild withdrawal → defer buprenorphine and reassess in 1–2 hours 1
• COWS 13–24 = moderate withdrawal → safe to initiate buprenorphine 1
• COWS 25–36 = moderately severe withdrawal → initiate buprenorphine 1
• COWS >36 = severe withdrawal → initiate buprenorphine 1

Only administer buprenorphine when COWS ≥8 to avoid precipitating withdrawal. 1

Day 1 Induction Protocol

Once COWS ≥8 is confirmed:

• Give initial dose of 4–8 mg sublingual buprenorphine-naloxone based on withdrawal severity 1
• Reassess after 30–60 minutes using repeat COWS scoring 1
• If withdrawal persists, provide additional 2–4 mg every 2 hours as needed 1
• Target total Day 1 dose of approximately 8 mg (range 4–8 mg) 1

Day 2 and Maintenance Dosing

• Day 2: Administer 16 mg total dose, which becomes the standard maintenance dose for most patients 1
• Standard maintenance: 16 mg sublingual daily (this dose occupies ~95% of mu-opioid receptors and creates a ceiling effect on respiratory depression) 2, 1
• Dose range: 4–24 mg daily may be used depending on individual response 1
• Once-daily dosing is preferred; twice-daily dosing (e.g., 8 mg BID) increases respiratory risk when combined with benzodiazepines 1

Managing Precipitated Withdrawal

If precipitated withdrawal occurs despite following the protocol:

• Administer MORE buprenorphine (not less) as the primary treatment—this is counterintuitive but pharmacologically sound and supported by case reports 1
• Adjunctive symptomatic management: 1
  • Clonidine 0.1–0.2 mg every 6–8 hours for autonomic symptoms (sweating, tachycardia, hypertension)
  • Antiemetics (promethazine or ondansetron) for nausea and vomiting
  • Benzodiazepines for anxiety and muscle cramps
  • Loperamide for diarrhea

Prescribing and Discharge Planning

• The X-waiver requirement was eliminated in 2023, allowing any DEA-licensed provider to prescribe buprenorphine-naloxone 1
• Discharge prescription: 16 mg sublingual daily for 3–7 days (or until first follow-up appointment) 1
• Provide take-home naloxone kit and overdose-prevention education 1
• Offer hepatitis C and HIV screening 1
• Consider reproductive health counseling 1

Duration of Treatment

Buprenorphine should not be discontinued once started for OUD, as discontinuation precipitates withdrawal and dramatically increases relapse risk to more dangerous opioids. 2

• There is no maximum recommended duration of maintenance treatment—patients may require treatment indefinitely 2
• Maintenance therapy is substantially more effective than tapering for preventing relapse in stable adults 2, 3
• The CDC recommends offering buprenorphine as medication-assisted maintenance rather than detoxification because maintenance better prevents relapse 2

Special Considerations for Chronic Pain

If the patient was taking Percocet for chronic pain rather than OUD:

• Buprenorphine has safety advantages over full mu-agonists because respiratory depression plateaus as dose increases, and it is less subject to dose escalation 2
• Buprenorphine can be used off-label as an analgesic for chronic pain without requiring an OUD diagnosis or DEA waiver 2
• Patients with poor pain control and poor functioning on high-dose opioids may benefit from switching to buprenorphine, particularly those with complex persistent opioid dependence 2

Common Pitfalls to Avoid

• Initiating buprenorphine when COWS <8 precipitates severe withdrawal 1
• Prescribing discharge doses below 16 mg daily often results in persistent withdrawal symptoms and treatment failure 1
• Attempting to taper buprenorphine rapidly leads to higher dropout rates and increased relapse to illicit opioid use 3
• Discontinuing buprenorphine to comply with opioid dose guidelines is inappropriate, as buprenorphine for OUD should not be reduced due to its ceiling effect on respiratory depression 2