Suboxone induction protocol

[yoloswagpoop42069]

Gearing up for my first job outside residency at an addiction recovery center (outpatient clinic)
Sad to say, residency training has not given me the volume of outpatient Suboxone patients to feel comfortable with all the details of Suboxone induction.

Looking online, there are a variety of Suboxone initiation protocols available, with variable dosing schedules.
Since I'm just getting started, I would like a concrete protocol to operate on for the first month, and then be more flexible and tailor it from there. All Suboxone initiations at the outpatient clinic will be home inductions (so no office-based induction/watching first dose).

What is your go-to Suboxone initiation prescribing protocols for reliable, health-literate patients, after the usual assessment/psychoeducation is provided?

From this ASAM guide it suggests flexible home dosing on Days 1-3:

https://www.asam.org/docs/default-source/education-docs/unobserved-home-induction-patient-guide.pdf?sfvrsn=16224bc2_0

But using this, I believe it then necessitates follow-up on Day 4 to address maintenance dosing?
And if using this protocol, I get confused on how many 4 mg tablets/strips I should prescribe so they are covered for the flexibility?

This Yale guide, based on ED-visit initiations, is way more concrete:

https://medicine.yale.edu/edbup/home_buprenorphine_initiation_338574_5_v1.pdf

With Day 1 dosing of three 4 mg strips for a total of 12 mg on Day 1
And then straight up 16 mg from Days 2-7
With follow-up 1 week later.

Right now, I am thinking about following the Yale ED protocol as it's more concrete, and I know exactly how many tabs/strips I need to prescribe, and allows for concrete follow-up in 1 week to assess maintenance dose. But since it goes quickly to 16 mg per day, I wonder about the patients who do not need so much, and perhaps need only 8 mg Daily, although I assume the majority of patients will need at least 16 mg, so maybe I can flex this protocol to 8 mg daily for those who are not using much per day, but still want Suboxone.

@SubzDoc or anyone else who routinely initiates Suboxone, your guidance in this would be appreciated.

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[ObsequiousAplomb]

Does your job have a specific protocol they want you to consider before trying your own? Oftentimes they do.

 

[allantois]

I agree with ASAM dosing. I would Rx them six 8 mg strips for 3 days and advise to take halves at a time (up to two strips a day). And then go from there

A lot of them have taken suboxone off the street and actually know how much they need lol

 

[SubzDoc]

When I started doing home inductions, there was a handout from NYU, the lee method for induction. It was longer and more complicated than what you posted. I found people couldn't really follow that set of instructions, even if the induction was successful. There is not a single method for induction. You will quickly get used to what works for your population and the different types of patients you are seeing. I sort of have a system I use. This is for people who are typically using heroin or high doses of Rx opioids. It would be overkill for people who are using more like therapeutic doses of Rx opioids. Also, it may not work well for people who are using good amounts of straight fentanyl. The risk of precip in fentanyl users really is higher and outpatient induction is harder. Some of them (the fentanyl pts) I had to send for methadone after multiple failed inductions. But this is the basic package:

I ask them about their typical withdrawal symptoms. Based on what they tell me, I prescribe some combination of comfort meds. Pick no more than 5 of clonidine, hydroxyzine, gabapentin, methocarbamol, loperamide, trazodone, ibuprofen, dicyclomine, zofran. I make them all available Q8H PRN. Then I prescribe a bottle of suboxone, either 8mg a day or 16mg a day, enough in number so that they can make it to the next appointment if they end up taking 16mg a day. I tell them not to take more or less suboxone than they need and actually they are pretty good about this, some come back taking 8mg or 12mg a day. Then I tell them induction is a 3 step process, follow the steps or they will have a bad time. I often write the steps down for them on a sheet of printer paper.

1) STOP using opioids.
2) Wait as long as you can and use the comfort medication. At least a day but longer is better.
3) Start suboxone, start with no more than 4mg and don't take more than 16mg in a day.

You have to remind them at several points to use the comfort medications during the pre-induction phase. I try to call them briefly the next day to see how they are doing and remind them to use the comfort meds. I don't think I have a had a precipitated withdrawal using this method, except when fentanyl was involved.

4mg can be too much for somebody who is not using a lot of Rx opioids. 2mg of SL buprenorphine is up to 150mg of PO morphine. And fentanyl complicates things. I have heard some say to use a micro-induction protocol for fentanyl, I have also tried recommending a longer pre-induction wait time and a lower starting dose of buprenorphine but I don't think there is a perfect solution.

Evidence of Buprenorphine-precipitated Withdrawal in... : Journal of Addiction Medicine

s We collected self-report data on opioid withdrawal symptoms after buprenorphine use, and, as a comparator, after methadone use, in 1679 individuals seeking treatment for opioid use disorder across 49 addiction treatment centers in the United States. Results The odds of developing severe...

journals.lww.com

I also did not mean to profess myself an expert on suboxone with my handle, I don't actually have an enormous panel. It came from a joke one of my colleagues made about a local, unscrupulous addiction doctor needing a vanity license plate.

I would also be interested to hear what others are doing.

 

[ObsequiousAplomb]

When I started doing home inductions, there was a handout from NYU, the lee method for induction. It was longer and more complicated than what you posted. I found people couldn't really follow that set of instructions, even if the induction was successful. There is not a single method for induction. You will quickly get used to what works for your population and the different types of patients you are seeing. I sort of have a system I use. This is for people who are typically using heroin or high doses of Rx opioids. It would be overkill for people who are using more like therapeutic doses of Rx opioids. Also, it may not work well for people who are using good amounts of straight fentanyl. The risk of precip in fentanyl users really is higher and outpatient induction is harder. Some of them (the fentanyl pts) I had to send for methadone after multiple failed inductions. But this is the basic package:

I ask them about their typical withdrawal symptoms. Based on what they tell me, I prescribe some combination of comfort meds. Pick no more than 5 of clonidine, hydroxyzine, gabapentin, methocarbamol, loperamide, trazodone, ibuprofen, dicyclomine, zofran. I make them all available Q8H PRN. Then I prescribe a bottle of suboxone, either 8mg a day or 16mg a day, enough in number so that they can make it to the next appointment if they end up taking 16mg a day. I tell them not to take more or less suboxone than they need and actually they are pretty good about this, some come back taking 8mg or 12mg a day. Then I tell them induction is a 3 step process, follow the steps or they will have a bad time. I often write the steps down for them on a sheet of printer paper.

1) STOP using opioids.
2) Wait as long as you can and use the comfort medication. At least a day but longer is better.
3) Start suboxone, start with no more than 4mg and don't take more than 16mg in a day.

You have to remind them at several points to use the comfort medications during the pre-induction phase. I try to call them briefly the next day to see how they are doing and remind them to use the comfort meds. I don't think I have a had a precipitated withdrawal using this method, except when fentanyl was involved.

4mg can be too much for somebody who is not using a lot of Rx opioids. 2mg of SL buprenorphine is up to 150mg of PO morphine. And fentanyl complicates things. I have heard some say to use a micro-induction protocol for fentanyl, I have also tried recommending a longer pre-induction wait time and a lower starting dose of buprenorphine but I don't think there is a perfect solution.

Evidence of Buprenorphine-precipitated Withdrawal in... : Journal of Addiction Medicine

s We collected self-report data on opioid withdrawal symptoms after buprenorphine use, and, as a comparator, after methadone use, in 1679 individuals seeking treatment for opioid use disorder across 49 addiction treatment centers in the United States. Results The odds of developing severe...

journals.lww.com

I also did not mean to profess myself an expert on suboxone with my handle, I don't actually have an enormous panel. It came from a joke one of my colleagues made about a local, unscrupulous addiction doctor needing a vanity license plate.

I would also be interested to hear what others are doing.

I could definitely see our mutual mentor having made this joke, and now I wonder if it was that doctor or someone you worked with later.

 

[SubzDoc]

I could definitely see our mutual mentor having made this joke, and now I wonder if it was that doctor or someone you worked with later.

It was not there although I could also see him saying that and there were a few similarly sketchy individuals around those parts.

 

[yoloswagpoop42069]

Does your job have a specific protocol they want you to consider before trying your own? Oftentimes they do.

I asked them and I asked the medical director and we will speak soon, however I don’t think there is a standard general protocol written down specifically for the providers at the clinic. I think its up to the prescriber's discretion. I did not want to ask the NP there how he/she does it, and would prefer to read online protocols and their rationals, as well as ask other physicians.

 

[yoloswagpoop42069]

"Then I prescribe a bottle of suboxone, either 8mg a day or 16mg a day, enough in number so that they can make it to the next appointment if they end up taking 16mg a day.

I tell them not to take more or less suboxone than they need and actually they are pretty good about this, some come back taking 8mg or 12mg a day.

3) Start suboxone, start with no more than 4mg and don't take more than 16mg in a day."

So basically since they start with a 4 mg dose, if you provide a script on Day 1, with follow-up in 1 week, exactly on Day 8, you'd write the script as Suboxone 4 mg/1mg, #32 tabs/films?

How do you write the dosing instructions -- take 1 film SL four times a day for the description on the bottle, but tell them to ignore the direction on the bottle and only take what they need for their f/u appointment?

I think I'm being too perfectionistic on making sure they have exactly the amount of tabs they need for appropriate coverage during week 1, when it doesn't really matter. It's not like you can profit much on just a few tabs (if they sell the excess), and if they were to overtake their tabs, wouldn't matter much anyway either, as long as they find their maintenance dose by the end of week 1. With the caveat of telling them I can't prescribe them any more than #32 tabs for this week, and to not aggressively overtake them.

 

[yoloswagpoop42069]

I agree with ASAM dosing. I would Rx them six 8 mg strips for 3 days and advise to take halves at a time (up to two strips a day). And then go from there

A lot of them have taken suboxone off the street and actually know how much they need lol

This makes sense, but would mandate all new Suboxone patients to follow-up on Day 4, if the clinic schedule allows it. I understand the rational for ASAM dosing based on how much they need Day 1, Day 2, and Day 3, but I think the majority of patients will not really read or follow that specific dosing protocol in that sheet to find the best dose by Day 4.

However, as long as they find the correct maintenance dose they need by Day 4, that's all that really matters.

 

[SubzDoc]

"Then I prescribe a bottle of suboxone, either 8mg a day or 16mg a day, enough in number so that they can make it to the next appointment if they end up taking 16mg a day.

I tell them not to take more or less suboxone than they need and actually they are pretty good about this, some come back taking 8mg or 12mg a day.

3) Start suboxone, start with no more than 4mg and don't take more than 16mg in a day."

So basically since they start with a 4 mg dose, if you provide a script on Day 1, with follow-up in 1 week, exactly on Day 8, you'd write the script as Suboxone 4 mg/1mg, #32 tabs/films?

How do you write the dosing instructions -- take 1 film SL four times a day for the description on the bottle, but tell them to ignore the direction on the bottle and only take what they need for their f/u appointment?

I think I'm being too perfectionistic on making sure they have exactly the amount of tabs they need for appropriate coverage during week 1, when it doesn't really matter. It's not like you can profit much on just a few tabs (if they sell the excess), and if they were to overtake their tabs, wouldn't matter much anyway either, as long as they find their maintenance dose by the end of week 1. With the caveat of telling them I can't prescribe them any more than #32 tabs for this week, and to not aggressively overtake them.

I use 8mg tablets and tell them to halve it for the first 4mg dose. I tell them to ignore the instructions on the bottle. I used to try to put instructions for titration on the bottle and the pharmacy, in their infinite wisdom, disallowed me from doing this. So now I just look at is as giving them a supply and a set of easy guidelines to follow to find a comfortable dose. It's better to give a little more than not enough. A little more you will not hear about, not enough you will hear about. You may find yourself surprised that the large majority of them don't play games with abusing/diverting this medication although your mileage may vary depending on population.

 

[yoloswagpoop42069]

I use 8mg tablets and tell them to halve it for the first 4mg dose. I tell them to ignore the instructions on the bottle. I used to try to put instructions for titration on the bottle and the pharmacy, in their infinite wisdom, disallowed me from doing this. So now I just look at is as giving them a supply and a set of easy guidelines to follow to find a comfortable dose. It's better to give a little more than not enough. A little more you will not hear about, not enough you will hear about. You may find yourself surprised that the large majority of them don't play games with abusing/diverting this medication although your mileage may vary depending on population.

Okay perfect, your responses have helped me a ton, thank you.

If following up in exactly 1 week (8 Days), I'll script Suboxone 8/2, take 1 film SL, BID, #16, and then in person tell them cut the film in half, flex the 4 mg dosing to get them feeling well for day 1-2ish, and then take the minimum amount per day until they see me again in day 8.

How long do you do 1 week follow-ups? for 1 month, then spread out to monthly?

 

[SubzDoc]

Okay perfect, your responses have helped me a ton, thank you.

If following up in exactly 1 week (8 Days), I'll script Suboxone 8/2, take 1 film SL, BID, #16, and then in person tell them cut the film in half, flex the 4 mg dosing to get them feeling well for day 1-2ish, and then take the minimum amount per day until they see me again in day 8.

How long do you do 1 week follow-ups? for 1 month, then spread out to monthly?

When I started I would see them weekly for a month then q2weeks for a month then monthly, decreasing the interval as long as they were performing well in treatment. Now, I still see them once within a week but as long as I'm getting a good feel from them I decrease the frequency rapidly.

I would ask what the others do at the treatment center, it helps if you are doing more or less the same thing as everyone else.

 

[allantois]

Alternatively you can start them 4 mg bid and see them in a week. Ultimately if you can’t see them back within a few days, I wouldn’t be starting them on suboxone

 

[calvnandhobbs68]

Yeah I did all home inductions a few years ago when I did this for moonlighting in fellowship and basically just used the ASAM handout you already found. I'd tell them they didn't really need to do the stuff about calling the office to check in unless they felt the induction was going badly. Biggest thing is they need to be in withdrawal before they started, but the rule overall was that they typically needed to be in at least some withdrawal before they came to their clinic appointment so we could do the prescription there and they could start relatively quickly. @SubzDoc is pretty much what we'd do. I'd also give them scripts for gabapentin 300mg TID and clonidine 0.1-0.2mg TID for like 3-4 days? Don't remember the exact days now.

Agree that a lot of these patients have actually used suboxone before off the street to try this on their own and so have a sense of at least what things feel like (super helpful actually if they know what precipitated withdrawal feels like because they know it feels like total **** and they really need to be in withdrawal before starting the suboxone).

We'd see them back within a week. Our population was mostly high dose prescription opioids though, not really fentanyl.

 

[hallowmann]

Honestly there's lots of different protocols, but ultimately like described above one where they are taking 8-16 mg daily after the induction until follow-up a week later is really typical. If you're worried about fentanyl, you can use a Bernese method or modified one to your liking, but beyond that, most people can tell when they are in withdrawal and start then. Even if they precipitate, I've been seeing a lot of people touting macrodose induction as well, but have less experience with that. Suboxone is a hell of a med.

 

[yoloswagpoop42069]

Alternatively you can start them 4 mg bid and see them in a week. Ultimately if you can’t see them back within a few days, I wouldn’t be starting them on suboxone

Yeah I was thinking about this too but in my mind that’s not the best care as I think a lot of patients 8 mgs per day won’t fully cover them.

And like subz says if you aren’t fully covering them theyre going to call you. And it’s not even about being bothered at that point it’s about providing good care, and at that point they have a risk of using on top of the 8 mgs or just stopping the induction.

 

[yoloswagpoop42069]

Yeah I did all home inductions a few years ago when I did this for moonlighting in fellowship and basically just used the ASAM handout you already found. I'd tell them they didn't really need to do the stuff about calling the office to check in unless they felt the induction was going badly. Biggest thing is they need to be in withdrawal before they started, but the rule overall was that they typically needed to be in at least some withdrawal before they came to their clinic appointment so we could do the prescription there and they could start relatively quickly. @SubzDoc is pretty much what we'd do. I'd also give them scripts for gabapentin 300mg TID and clonidine 0.1-0.2mg TID for like 3-4 days? Don't remember the exact days now.

Agree that a lot of these patients have actually used suboxone before off the street to try this on their own and so have a sense of at least what things feel like (super helpful actually if they know what precipitated withdrawal feels like because they know it feels like total **** and they really need to be in withdrawal before starting the suboxone).

We'd see them back within a week. Our population was mostly high dose prescription opioids though, not really fentanyl.

Yeah I did all home inductions a few years ago when I did this for moonlighting in fellowship and basically just used the ASAM handout you already found. I'd tell them they didn't really need to do the stuff about calling the office to check in unless they felt the induction was going badly. Biggest thing is they need to be in withdrawal before they started, but the rule overall was that they typically needed to be in at least some withdrawal before they came to their clinic appointment so we could do the prescription there and they could start relatively quickly. @SubzDoc is pretty much what we'd do. I'd also give them scripts for gabapentin 300mg TID and clonidine 0.1-0.2mg TID for like 3-4 days? Don't remember the exact days now.

Agree that a lot of these patients have actually used suboxone before off the street to try this on their own and so have a sense of at least what things feel like (super helpful actually if they know what precipitated withdrawal feels like because they know it feels like total **** and they really need to be in withdrawal before starting the suboxone).

We'd see them back within a week. Our population was mostly high dose prescription opioids though, not really fentanyl.

Yeah thanks all responses have been helpful

I guess with the ASAM guide I was just confused on what dose to prescribe and how many tabs on the actual script, since the dosage flexes over 3 days, but like subz said if follow ups in a week you can just script out 8 mg BID for 8 days, give them the ASAM guide if you want and explain it, telling them to cut it in half.

Or in other less commercial clinics they may just do the strict ASAM and follow up in 3 days with some 4 mg films being given.

All of it depends on health literacy anyway and how savvy the patient is. Like you guys said most have used it off the street and know how it works. A lot of people who have SUDs have decent pharm knowledge in terms of psychoactives.

Regardless I have clarified in my own mind what I want to do.

Thanks all.

 

[nexus73]

Bumping this thread to ask if people are doing high dose Subxone inductions.

I recently saw a patient in hospital who was treated at a Suboxone clinic and prescribed 16 mg initial dose, then 8 mg after 1st hour, and another 8 mg after 2nd hour if needed, for max of 32 mg on the first day. I reviewed the clinic note and no mention of a COWS and physical exam and vitals reflected no withdrawal. Doc just asked if it was more than 24-48 hours since he last used, patient said yes (he wasn't), then proceeded to go home and take the 16 mg and go into a pretty severe precipitated withdrawal (had been on Kadian extended release morphine). He didn't take the next to 8 mg dose options.

I reviewed and found an article from 2021 of high dose induction being done in EDs, but wasn't sure if this was happening outpatient. It seemed odd to me especially with a home induction.

 

[allantois]

What's the reason for doing high dose induction? Getting rx denied by the pharmacy? lol

 

[vanfanal]

Bumping this thread to ask if people are doing high dose Subxone inductions.

I recently saw a patient in hospital who was treated at a Suboxone clinic and prescribed 16 mg initial dose, then 8 mg after 1st hour, and another 8 mg after 2nd hour if needed, for max of 32 mg on the first day. I reviewed the clinic note and no mention of a COWS and physical exam and vitals reflected no withdrawal. Doc just asked if it was more than 24-48 hours since he last used, patient said yes (he wasn't), then proceeded to go home and take the 16 mg and go into a pretty severe precipitated withdrawal (had been on Kadian extended release morphine). He didn't take the next to 8 mg dose options.

I reviewed and found an article from 2021 of high dose induction being done in EDs, but wasn't sure if this was happening outpatient. It seemed odd to me especially with a home induction.

I do it. It’s called macrodosing. The idea is to push past any precipitated withdrawal that’s likely to happen in the fentanyl age. I usually do 8mg every hour until settled.

Some others will give sublocade as soon as day 2.

 

[hallowmann]

Bumping this thread to ask if people are doing high dose Subxone inductions.

I recently saw a patient in hospital who was treated at a Suboxone clinic and prescribed 16 mg initial dose, then 8 mg after 1st hour, and another 8 mg after 2nd hour if needed, for max of 32 mg on the first day. I reviewed the clinic note and no mention of a COWS and physical exam and vitals reflected no withdrawal. Doc just asked if it was more than 24-48 hours since he last used, patient said yes (he wasn't), then proceeded to go home and take the 16 mg and go into a pretty severe precipitated withdrawal (had been on Kadian extended release morphine). He didn't take the next to 8 mg dose options.

I reviewed and found an article from 2021 of high dose induction being done in EDs, but wasn't sure if this was happening outpatient. It seemed odd to me especially with a home induction.

It can be done outpatient. Have certainly seen it, only done it in training once or twice before. It is done in outpatient. I once had a patient essentially do a home macroinduction on their own when normal induction put them into withdrawal (instead of continuing to take 2 mg, they took an 8 mg), then settled at 16 mg daily by the time I saw them a week later. They did fine.

Its not great to not have a COWS or vitals on the note though. Maybe there is a separate nursing note that you didn't see... or maybe they just didn't do it. Patient probably would have been OK if they took the other doses as planned, but who knows. I have not run into many problems getting 24-32 mg daily approved by insurance or pharmacies (if they carry Suboxone to begin with), especially if you're talking tablets.

 

[nexus73]

It can be done outpatient. Have certainly seen it, only done it in training once or twice before. It is done in outpatient. I once had a patient essentially do a home macroinduction on their own when normal induction put them into withdrawal (instead of continuing to take 2 mg, they took an 8 mg), then settled at 16 mg daily by the time I saw them a week later. They did fine.

Its not great to not have a COWS or vitals on the note though. Maybe there is a separate nursing note that you didn't see... or maybe they just didn't do it. Patient probably would have been OK if they took the other doses as planned, but who knows. I have not run into many problems getting 24-32 mg daily approved by insurance or pharmacies (if they carry Suboxone to begin with), especially if you're talking tablets.

Is there a guide for high dose induction you could point me toward?

 

[hallowmann]

Is there a guide for high dose induction you could point me toward?

Resources - Bridge to Treatment

Our resources have been developed by an interdisciplinary team based on published evidence and expert opinion.

cabridge.org

Its technically for ED, but most of the protocol is outpatient based and if they come to you not in acute withdrawal it has another side to the algorithm.

Many ED Bridge programs work like this. You prescribe enough for 7-14 days, and plan for outpatient follow-up. Most of the time the induction is not done in the ED (usually home induction unless they are actively in withdrawal), and as long as you can secure outpatient follow-up within 1-2 wks, this is common in many places.