Buprenorphine Treatment for Opioid Use Disorder

Medication Overview and Selection

Buprenorphine is a partial mu-opioid receptor agonist with high receptor affinity that reduces cravings and withdrawal symptoms while having a ceiling effect on respiratory depression, making it safer than full agonists like methadone, as recommended by the American Academy of Pediatrics 1, 2

The American College of Emergency Physicians recommends that buprenorphine must ONLY be initiated when patients are in active opioid withdrawal, confirmed by both history and physical examination, to avoid precipitated withdrawal 3, 4, 5
The Clinical Opiate Withdrawal Scale (COWS) should be used to objectively assess withdrawal severity before initiating buprenorphine, as suggested by the American College of Emergency Physicians 3, 4, 5

The therapeutic dose range is 8-16 mg daily, with 16 mg being optimal for most patients, according to the American College of Emergency Physicians 2

Buprenorphine must be combined with counseling and behavioral therapies to provide a "whole-patient" approach—medication alone is insufficient, as recommended by the American College of Emergency Physicians 3, 4, 5

The American Academy of Pediatrics recommends that pediatricians consider offering medication-assisted treatment to adolescents and young adults with severe opioid use disorders 6, 1
The American College of Obstetricians and Gynecologists recommends Subutex (buprenorphine alone) over Suboxone during pregnancy 2

Regular urine drug testing should be conducted to assess for continued illicit opioid use, as recommended by the American Society of Addiction Medicine 2
Patients should be assessed for opioid use disorder using DSM-5 criteria during follow-up visits, according to the American Psychiatric Association 2
Hepatitis C and HIV screening should be offered as part of comprehensive care, as recommended by the Centers for Disease Control and Prevention 4, 5, 2

For patients requiring acute pain management while on buprenorphine maintenance, the usual buprenorphine dose should be continued and short-acting opioid analgesics used as needed for breakthrough pain, as suggested by the American Pain Society 2
Buprenorphine's high binding affinity may block effects of other opioids at lower doses, potentially requiring higher analgesic doses, according to the American Pain Society 2