Buprenorphine/Naloxone (Trade name: Suboxone) is a combination medication used in opioid replacement therapy in opioid use disorder, and chronic pain management. Buprenorphine is a partial opioid agonist, while naloxone is a competitive opioid antagonist added to prevent misuse.
Short-Acting Opioid | Intermediate-Acting Opioid | Long-Acting Opioid | |
---|---|---|---|
Example | Heroin, morphine, hydrocodone, immediate-release oxycodone | Slow-release oral morphine, controlled-release hydromorphone, sustained-release oxycodone | Methadone |
Tapering Schedule | Stop at midnight | Stop at midnight | Reduce methadone by up to 30mg per day over a period of 1 week |
Onset of Moderate Withdrawal Symptoms (i.e. - COWS > 12) | 12–16 hours after last dose | 17–24 hours after last dose | 30–48 hours (or more) after last dose |
When to Start Induction | As soon as COWS > 12 | As soon as COWS > 12 | Wait at least 24 hours, but preferably 48–72 hours after last methadone dose if patient can tolerate withdrawal symptoms, before beginning induction |
If there are no withdrawal symptoms present since last dose, continue with a once daily dose equal to the total amount administered on Day 1. It is appropriate to increase the dose by 2–4 mg per day if the patient continues to report withdrawal symptoms or cravings. Each dose increase should increase duration of relief from withdrawal and cravings. The typical maintenance dose is usually 8 to 16 mg daily, with a maximum dose of 24 mg daily. Higher doses have been noted in case reports. An optimal dose will relieve withdrawal symptoms and cravings for 24 hours. During the titration phase, clinicians should ask for common side effects such as sedation.
Buprenorphine Dose | Number of Consecutive Days Missed | Missed New Starting Dose |
---|---|---|
> 8 mg | > 7 days | 4 mg |
> 8 mg | 6-7 days | 8 mg |
6-8 mg | 6 or more days | 4 mg |
2-4 mg | 6 or more days | 2-4 mg |
A common starting dose for the Burnese induction method is buprenorphine 0.5 mg, which involves splitting the Suboxone 2 mg/0.5 mg tablet into quarters. Here are is a sample micro-induction schedule for individuals on short-acting opioids:
Day | Buprenorphine / Naloxone | Opioid |
---|---|---|
1 | 0.5 mg daily | Maintain dose |
2 | 1.0 mg daily | Maintain dose |
3 | 1.5 mg daily | Maintain dose |
4 | 2.0 mg daily | Maintain dose |
5 | 2.5 mg daily | Maintain dose |
6 | 3.0 mg daily | Maintain dose |
7 | 4.0 mg daily | Stop short-acting opioid |
Guideline | Location | Year | Website | |
---|---|---|---|---|
Canadian Medical Association Journal (CMAJ) | Canada | 2018 | - | Link |
BC Centre on Substance Use (BCCSU) | Canada | 2023 | Link | Link |
META:PHI | Canada | 2019 | Link | Link |
Canadian Guidelines on Opioid Use Disorder Among Older Adults | Canada | 2020 | Link | |
National Institute for Health and Care Excellence (NICE) | UK | 2007 | - | Link |
American Psychiatric Association | USA | 2006, 2007 | - | • Guideline (2006) • Guideline Watch (2007) • Quick Reference |