Buprenorphine - Revision history

Danbot: Reduce excessive bold: 32->9 instances; keep only critical safety warnings

2026-03-22T08:47:58Z

Reduce excessive bold: 32->9 instances; keep only critical safety warnings

Danbot: Switch SMW query from broadtable to table format for better layout with TOC

2026-03-20T21:57:47Z

Switch SMW query from broadtable to table format for better layout with TOC

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Danbot: Fix SMW query: replace link=subject with mainlabel=- to fix broken subobject fragment links

2026-03-20T17:25:57Z

Fix SMW query: replace link=subject with mainlabel=- to fix broken subobject fragment links

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Danbot: Add dynamic SMW Indications by Condition table (auto-populated from disease pages via MedicationDose template)

2026-03-20T16:44:06Z

Add dynamic SMW Indications by Condition table (auto-populated from disease pages via MedicationDose template)

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 *Patients presenting on extended-release buprenorphine (Sublocade, Brixadi) who have breakthrough withdrawal may need supplemental sublingual buprenorphine — consult with the patient's prescriber
 *For patients with OUD in the ED who decline buprenorphine, still treat withdrawal symptoms, provide harm reduction resources ([[Special:MyLanguage/naloxone|naloxone kit]], fentanyl test strips), and offer a prescription or referral for a future visit
 ==See Also==

Ostermayer at 17:44, 10 March 2026

2026-03-10T17:44:57Z

Show changes

Ostermayer: /* Opioid withdrawal */

2024-07-04T09:24:01Z

Opioid withdrawal

← Revisión anterior		Revisión del 09:24 4 jul 2024
Línea 9:		Línea 9:
	''Highly variable, dependent on individual. The below dosing is for the traditional induction, although there are also options including a micro-induction (low-dose induction) for patients not in opioid withdrawal or a high-dose induction.'' <ref> Weimer MB, Herring AA, Kawasaki SS, Meyer M, Kleykamp BA, Ramsey KS. ASAM Clinical Considerations: Buprenorphine Treatment of Opioid Use Disorder for Individuals Using High-potency Synthetic Opioids. J Addict Med. 2023 Jul 28. doi: 10.1097/ADM.0000000000001202. Epub ahead of print. PMID: 37505909. </ref>		''Highly variable, dependent on individual. The below dosing is for the traditional induction, although there are also options including a micro-induction (low-dose induction) for patients not in opioid withdrawal or a high-dose induction.'' <ref> Weimer MB, Herring AA, Kawasaki SS, Meyer M, Kleykamp BA, Ramsey KS. ASAM Clinical Considerations: Buprenorphine Treatment of Opioid Use Disorder for Individuals Using High-potency Synthetic Opioids. J Addict Med. 2023 Jul 28. doi: 10.1097/ADM.0000000000001202. Epub ahead of print. PMID: 37505909. </ref>
	===[[Opioid withdrawal]]===		===[[Opioid withdrawal]]===
	*For [https://www.mdcalc.com/cows-score-opiate-withdrawal Clinical Opioid Withdrawal Scale] (COWS) >=8: 4 to 8mg, observe 30 to 45min, redose if COWS remains >=8. Then discharge home with 16 mg a day to bridge until follow-up (an X-waiver is no longer required to prescribe buprenorphine).		{{Suboxone protocol}}
	*For Clinical Opioid Withdrawal Scale (COWS) 0-7: Consider observing the patient until their COWS score is >8 for the standard buprenorphine induction. Alternatively, you can prescribe consider unobserved home induction instructions available on paper <ref>A Guide for Patients Beginning Buprenorphine Treatment at Home https://medicine.yale.edu/edbup/quickstart/Home_Buprenorphine_Initiation_338574_42801_v1.pdf</ref><ref>A Patient’s Guide to Starting Buprenorphine at Home from ASAM https://www.asam.org/docs/default-source/education-docs/unobserved-home-induction-patient-guide.pdf</ref> and app<ref>Buprenorphine Home Induction Apple App Store https://apps.apple.com/us/app/buprenorphine-home-induction/id1449302173</ref> <ref>Starting Buprenorphine from Google Play Store https://play.google.com/store/apps/details?id=com.amstonstudio.bup&hl=en_US&gl=US</ref>.

	*If sublingual tablets/films unavailable then intravenous/intramuscular formulation (dose 0.3-0.9 mg every 6-12 hours) has been used for opioid withdrawal in the ED<ref>Berg ML, et. al. Evaluation of the use of buprenorphine for opioid withdrawal in an emergency department. Drug Alcohol Depend. 2007 Jan 12;86(2-3):239-44. https://doi.org/10.1016/j.drugalcdep.2006.06.014. Epub 2006 Aug 22. PMID: 16930865.</ref> and hospitalized<ref>Welsh CJ, Suman M, Cohen A, et al. The use of intravenous buprenorphine for the treatment of opioid withdrawal in medically ill hospitalized patients. Am J Addict. 2002;11(2):135-40 https://doi.org/10.1080/105500490290087901</ref> patients.

	~~[[File:Buprenorphine in ED.png\|thumb\|NIH National Institute on Drug Abuse ED Buprenorphine algorithm<ref>https://d14rmgtrwzf5a.cloudfront.net/sites/default/files/algorithm.pdf</ref>]]~~

	==Pediatric Dosing==		==Pediatric Dosing==

Cmb23: /* Comments */

2023-10-03T19:07:18Z

Comments

← Revisión anterior		Revisión del 19:07 3 oct 2023
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	==Comments==		==Comments==
	*Combined with naloxone to deter abuse. The naloxone has no effect when used as intended under the tongue. The naloxone is only active when abused by crushing/injection. Buprenorphine and buprenorphine/naloxone are interchangeable. Buprenorphine/naloxone is now generic in the USA.		*Combined with naloxone to deter abuse. The naloxone has no effect when used as intended under the tongue. The naloxone is only active when abused by crushing/injection. Buprenorphine and buprenorphine/naloxone are interchangeable. Buprenorphine/naloxone is now generic in the USA.
	*No DATA 2000 Waiver (aka X Waiver) required ~~to administer within the ED for up to 72h (e.g. patient can come back to ED for daily dose for 3 days)~~<ref>https://www.drugabuse.gov/nidamed-medical-health-professionals/discipline-specific-resources/initiating-buprenorphine-treatment-in-emergency-department/frequently-asked-questions-about-ed-initiated-buprenorphine</ref>		*The DATA 2000 Waiver (aka X Waiver) is no longer required <ref>https://www.drugabuse.gov/nidamed-medical-health-professionals/discipline-specific-resources/initiating-buprenorphine-treatment-in-emergency-department/frequently-asked-questions-about-ed-initiated-buprenorphine</ref>

	==See Also==		==See Also==

Cmb23: /* Special Populations */

2023-10-03T19:05:39Z

Special Populations

← Revisión anterior		Revisión del 19:05 3 oct 2023
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	==Special Populations==		==Special Populations==
	*[[Drug Ratings in Pregnancy\|Pregnancy Rating]]: C		*[[Drug Ratings in Pregnancy\|Pregnancy Rating]]: C (but buprenorphine is preferred over methadone in pregnant patients due to neonatal outcomes)
	*[[Lactation risk categories\|Lactation risk]]: Infant risk has been demonstrated		*[[Lactation risk categories\|Lactation risk]]: Infant risk has been demonstrated
	*Hepatic dosing: reduce dose or do not use in moderate - severe impairment		*Hepatic dosing: reduce dose or do not use in moderate - severe impairment
	*Renal dosing:		*Renal dosing:

	==Contraindications==		==Contraindications==

Cmb23: /* Opioid withdrawal */

2023-10-03T19:04:43Z

Opioid withdrawal

← Revisión anterior		Revisión del 19:04 3 oct 2023
Línea 9:		Línea 9:
	''Highly variable, dependent on individual. The below dosing is for the traditional induction, although there are also options including a micro-induction (low-dose induction) for patients not in opioid withdrawal or a high-dose induction.'' <ref> Weimer MB, Herring AA, Kawasaki SS, Meyer M, Kleykamp BA, Ramsey KS. ASAM Clinical Considerations: Buprenorphine Treatment of Opioid Use Disorder for Individuals Using High-potency Synthetic Opioids. J Addict Med. 2023 Jul 28. doi: 10.1097/ADM.0000000000001202. Epub ahead of print. PMID: 37505909. </ref>		''Highly variable, dependent on individual. The below dosing is for the traditional induction, although there are also options including a micro-induction (low-dose induction) for patients not in opioid withdrawal or a high-dose induction.'' <ref> Weimer MB, Herring AA, Kawasaki SS, Meyer M, Kleykamp BA, Ramsey KS. ASAM Clinical Considerations: Buprenorphine Treatment of Opioid Use Disorder for Individuals Using High-potency Synthetic Opioids. J Addict Med. 2023 Jul 28. doi: 10.1097/ADM.0000000000001202. Epub ahead of print. PMID: 37505909. </ref>
	===[[Opioid withdrawal]]===		===[[Opioid withdrawal]]===
	*For [https://www.mdcalc.com/cows-score-opiate-withdrawal Clinical Opioid Withdrawal Scale] (COWS) >=8: 4 to 8mg, observe 30 to 45min, redose if COWS remains >=8. Then discharge home with 16 mg a day ~~for 2 days if you are able~~ to prescribe~~, other wise consider return to the ER on day 2 and 3 for a 16 mg dose per day~~.		*For [https://www.mdcalc.com/cows-score-opiate-withdrawal Clinical Opioid Withdrawal Scale] (COWS) >=8: 4 to 8mg, observe 30 to 45min, redose if COWS remains >=8. Then discharge home with 16 mg a day to bridge until follow-up (an X-waiver is no longer required to prescribe buprenorphine).
	*For Clinical Opioid Withdrawal Scale (COWS) 0-7: Consider observing the patient until their COWS score is >8 for the standard buprenorphine induction. Alternatively, you can prescribe consider unobserved home induction instructions available on paper <ref>A Guide for Patients Beginning Buprenorphine Treatment at Home https://medicine.yale.edu/edbup/quickstart/Home_Buprenorphine_Initiation_338574_42801_v1.pdf</ref><ref>A Patient’s Guide to Starting Buprenorphine at Home from ASAM https://www.asam.org/docs/default-source/education-docs/unobserved-home-induction-patient-guide.pdf</ref> and app<ref>Buprenorphine Home Induction Apple App Store https://apps.apple.com/us/app/buprenorphine-home-induction/id1449302173</ref> <ref>Starting Buprenorphine from Google Play Store https://play.google.com/store/apps/details?id=com.amstonstudio.bup&hl=en_US&gl=US</ref>.		*For Clinical Opioid Withdrawal Scale (COWS) 0-7: Consider observing the patient until their COWS score is >8 for the standard buprenorphine induction. Alternatively, you can prescribe consider unobserved home induction instructions available on paper <ref>A Guide for Patients Beginning Buprenorphine Treatment at Home https://medicine.yale.edu/edbup/quickstart/Home_Buprenorphine_Initiation_338574_42801_v1.pdf</ref><ref>A Patient’s Guide to Starting Buprenorphine at Home from ASAM https://www.asam.org/docs/default-source/education-docs/unobserved-home-induction-patient-guide.pdf</ref> and app<ref>Buprenorphine Home Induction Apple App Store https://apps.apple.com/us/app/buprenorphine-home-induction/id1449302173</ref> <ref>Starting Buprenorphine from Google Play Store https://play.google.com/store/apps/details?id=com.amstonstudio.bup&hl=en_US&gl=US</ref>.

Cmb23: /* Opioid withdrawal */

2023-09-28T17:15:51Z

Opioid withdrawal

← Revisión anterior		Revisión del 17:15 28 sep 2023
Línea 7:		Línea 7:

	==Adult Dosing==		==Adult Dosing==
	''Highly variable, dependent on individual''		''Highly variable, dependent on individual. The below dosing is for the traditional induction, although there are also options including a micro-induction (low-dose induction) for patients not in opioid withdrawal or a high-dose induction.'' <ref> Weimer MB, Herring AA, Kawasaki SS, Meyer M, Kleykamp BA, Ramsey KS. ASAM Clinical Considerations: Buprenorphine Treatment of Opioid Use Disorder for Individuals Using High-potency Synthetic Opioids. J Addict Med. 2023 Jul 28. doi: 10.1097/ADM.0000000000001202. Epub ahead of print. PMID: 37505909. </ref>
	===[[Opioid withdrawal]]===		===[[Opioid withdrawal]]===
	*For [https://www.mdcalc.com/cows-score-opiate-withdrawal Clinical Opioid Withdrawal Scale] (COWS) >=8: ~~4mg~~, observe 45min, redose if COWS remains >=8. Then discharge home with 16 mg a day for 2 days if you are able to prescribe, other wise consider return to the ER on day 2 and 3 for a 16 mg dose per day.		*For [https://www.mdcalc.com/cows-score-opiate-withdrawal Clinical Opioid Withdrawal Scale] (COWS) >=8: 4 to 8mg, observe 30 to 45min, redose if COWS remains >=8. Then discharge home with 16 mg a day for 2 days if you are able to prescribe, other wise consider return to the ER on day 2 and 3 for a 16 mg dose per day.
	*For Clinical Opioid Withdrawal Scale (COWS) 0-7: ~~Do not dose in~~ the ER. If you can prescribe consider unobserved home induction instructions available on paper <ref>A Guide for Patients Beginning Buprenorphine Treatment at Home https://medicine.yale.edu/edbup/quickstart/Home_Buprenorphine_Initiation_338574_42801_v1.pdf</ref><ref>A Patient’s Guide to Starting Buprenorphine at Home from ASAM https://www.asam.org/docs/default-source/education-docs/unobserved-home-induction-patient-guide.pdf</ref> and app<ref>Buprenorphine Home Induction Apple App Store https://apps.apple.com/us/app/buprenorphine-home-induction/id1449302173</ref> <ref>Starting Buprenorphine from Google Play Store https://play.google.com/store/apps/details?id=com.amstonstudio.bup&hl=en_US&gl=US</ref>.		*For Clinical Opioid Withdrawal Scale (COWS) 0-7: Consider observing the patient until their COWS score is >8 for the standard buprenorphine induction. Alternatively, you can prescribe consider unobserved home induction instructions available on paper <ref>A Guide for Patients Beginning Buprenorphine Treatment at Home https://medicine.yale.edu/edbup/quickstart/Home_Buprenorphine_Initiation_338574_42801_v1.pdf</ref><ref>A Patient’s Guide to Starting Buprenorphine at Home from ASAM https://www.asam.org/docs/default-source/education-docs/unobserved-home-induction-patient-guide.pdf</ref> and app<ref>Buprenorphine Home Induction Apple App Store https://apps.apple.com/us/app/buprenorphine-home-induction/id1449302173</ref> <ref>Starting Buprenorphine from Google Play Store https://play.google.com/store/apps/details?id=com.amstonstudio.bup&hl=en_US&gl=US</ref>.

	*If sublingual tablets/films unavailable then intravenous/intramuscular formulation (dose 0.3-0.9 mg every 6-12 hours) has been used for opioid withdrawal in the ED<ref>Berg ML, et. al. Evaluation of the use of buprenorphine for opioid withdrawal in an emergency department. Drug Alcohol Depend. 2007 Jan 12;86(2-3):239-44. https://doi.org/10.1016/j.drugalcdep.2006.06.014. Epub 2006 Aug 22. PMID: 16930865.</ref> and hospitalized<ref>Welsh CJ, Suman M, Cohen A, et al. The use of intravenous buprenorphine for the treatment of opioid withdrawal in medically ill hospitalized patients. Am J Addict. 2002;11(2):135-40 https://doi.org/10.1080/105500490290087901</ref> patients.		*If sublingual tablets/films unavailable then intravenous/intramuscular formulation (dose 0.3-0.9 mg every 6-12 hours) has been used for opioid withdrawal in the ED<ref>Berg ML, et. al. Evaluation of the use of buprenorphine for opioid withdrawal in an emergency department. Drug Alcohol Depend. 2007 Jan 12;86(2-3):239-44. https://doi.org/10.1016/j.drugalcdep.2006.06.014. Epub 2006 Aug 22. PMID: 16930865.</ref> and hospitalized<ref>Welsh CJ, Suman M, Cohen A, et al. The use of intravenous buprenorphine for the treatment of opioid withdrawal in medically ill hospitalized patients. Am J Addict. 2002;11(2):135-40 https://doi.org/10.1080/105500490290087901</ref> patients.


	*Suboxone initial induction dose: 2mg/0.5mg or 4mg/1mg, titrate up by 2-4mg q2h based on withdrawal symptoms up to 8mg/1mg<ref>Suboxone prescribing pamphlet https://www.suboxone.com/hcp/induction-phase</ref>



	[[File:Buprenorphine in ED.png\|thumb\|NIH National Institute on Drug Abuse ED Buprenorphine algorithm<ref>https://d14rmgtrwzf5a.cloudfront.net/sites/default/files/algorithm.pdf</ref>]]		[[File:Buprenorphine in ED.png\|thumb\|NIH National Institute on Drug Abuse ED Buprenorphine algorithm<ref>https://d14rmgtrwzf5a.cloudfront.net/sites/default/files/algorithm.pdf</ref>]]