Buprenorphine Induction and Maintenance for Opioid Use Disorder

Standard Induction Protocol

The American College of Obstetricians and Gynecologists recommends that patients abstain from short-acting opioids for 12-24 hours and long-acting opioids for 36-48 hours before initiating buprenorphine, and demonstrate at least mild withdrawal symptoms on a validated scale to avoid precipitated withdrawal 1, 2
Patients must verify withdrawal symptoms using a validated opioid withdrawal scale before administering any buprenorphine, with a target score of 8-12 on the COWS scale 1, 2
Abstinence periods are mandatory, with 12-24 hours for short-acting opioids and 36-48 hours for long-acting opioids, to minimize the risk of precipitated withdrawal 1, 2
The initial dose of buprenorphine/naloxone should be 2-4 mg sublingually, with reassessment of withdrawal symptoms 30 minutes after the first dose using the same validated scale 1, 2
The target total dose on Day 1 is 8 mg, with a range of 4-8 mg depending on tolerance, and the dose should be titrated based on withdrawal symptoms and cravings 1, 2

The target maintenance dose of buprenorphine is 16 mg daily, which suppresses illicit opioid use in most patients, with a dosing range of 4-24 mg daily adjusted based on withdrawal symptoms and cravings 1, 2
Higher doses may be needed during pregnancy, with 2-4 times daily dosing, and increasing gestational age 1, 2

Patients must be stabilized on 8-24 mg daily sublingual/buccal buprenorphine for a minimum of 7 consecutive days before transitioning to monthly injectable buprenorphine (Sublocade) 3
The first two monthly doses of Sublocade should be 300 mg subcutaneous injection, followed by maintenance doses of 100 mg monthly thereafter 3

The American College of Obstetricians and Gynecologists recommends that concomitant use of buprenorphine with QT-prolonging agents is contraindicated due to the risk of QT interval prolongation 4, 3
There is a risk of serotonin syndrome when buprenorphine is combined with serotonergic agents, and a risk of paralytic ileus with anticholinergic medications 4, 3
Buprenorphine should not be withheld in patients using benzodiazepines, but rather used with careful medication management 1, 2

The American College of Obstetricians and Gynecologists recommends that buprenorphine/naloxone combination be continued in pregnancy if already prescribed, as the theoretical concerns about naloxone precipitating fetal withdrawal are not supported by evidence 1, 2
Buprenorphine results in less severe neonatal opioid withdrawal syndrome, shorter treatment duration, and shorter hospital stays compared to methadone 5, 2
Higher and more frequent dosing (2-4 times daily) may be required as pregnancy progresses 1, 2

The decision to continue or hold buprenorphine should reflect the prescribed daily dose, indication, relapse risk, and expected postoperative pain level, with close coordination with anesthesiology regarding timing and dosing 4

The American College of Obstetricians and Gynecologists recommends that standard buprenorphine induction should never be initiated without confirmed withdrawal symptoms, as this is the most common cause of precipitated withdrawal 1, 2
Oral naloxone should not be used for overdose reversal, and instead intranasal, subcutaneous, intramuscular, or intravenous routes should be used 4
Switching from methadone to buprenorphine requires close monitoring due to withdrawal risk, while switching from buprenorphine to methadone can be done immediately if no sedation is present 1, 2