Buprenorphine/Naloxone
Opioid use disorder (OUD), Opioid withdrawal management, ED-initiated buprenorphine for OUD
Indications
- Opioid use disorder (OUD)
- Opioid withdrawal management
- ED-initiated buprenorphine for OUD
Adult dosing
- induction: dose: 4; unit: mg SL; route: Sublingual; interval: May re-dose 4mg SL q1-2h; target 8-16mg on day 1; fixed: true; maintenance: dose: 16; unit: mg SL; route: Sublingual daily; interval: Range 8-24mg daily; fixed: true
Contraindications
- Active opioid intoxication
- Severe hepatic impairment
Clinical pearls
- Wait for COWS ≥8-12 before traditional induction to avoid precipitated withdrawal
- Low-dose (micro-dosing) induction protocols available for patients unable to tolerate withdrawal
- ED-initiated buprenorphine doubles treatment engagement at 30 days (D'Onofrio et al., JAMA 2015)
- X-waiver requirement eliminated in 2023 — any DEA-licensed provider can prescribe
- Naloxone component prevents IV misuse — inactive when taken sublingually
Source and review
- SAMHSA TIP 63; D'Onofrio et al., JAMA 2015. Last reviewed: 2024-11-01