BUPRENORPHINE

FDA approved for Opioid Use Disorder treatment in an officebased setting.

For those with tolerance to opioids as a result of OUD,

buprenorphine is often a safe choice.

Buprenorphine acts as a partial mixed opioid agonist at the μreceptor and as an antagonist at the κ-receptor. It has a higher

affinity for the μ-receptor than other opioids, and it can

precipitate withdrawal symptoms in those actively using other

opioids.

It is dosed daily, has a long half-life, and prevents withdrawal in

opioid dependent patients.

Can be in tablet, sublingual film, or injectable formulations.

Many formulations contain naloxone to prevent injection

diversion. This formulation is the preferred treatment medication.

The buprenorphine only version is often used with pregnant

women to decrease potential fetal exposure to naloxone.

There is a “ceiling effect” in which further increases above 24mg in

dosage does not increase the effects on respiratory or

cardiovascular function.

Buprenorphine should be part of a comprehensive management

program that includes psychosocial support. Treatment should

not be withheld in the absence of psychosocial support.

Overdose with buprenorphine in adults is less common, and most

likely occurs in individuals without tolerance, or who are using cooccurring substances like alcohol or benzodiazepines.

QUICK START GUIDE

Important Points to

ReviewWith the

Patient

Understand that

discontinuing

buprenorphine

increases risk of

overdose death upon

return to illicit

opioid use.

Know that use of

alcohol or

benzodiazepines

with buprenorphine

increases the risk of

overdose and death.

Understand the

importance of

informing providers

if they become

pregnant.

Tell providers if they

are having a

procedure that may

require pain

medication.

Specifically discuss

safety concerns:

A patient history

Ensure that the assessment includes a medical

and psychiatric history, a substance use

history, and an evaluation of family and

psychosocial supports.

Access the patient’s prescription drug use

history through the state’s Prescription Drug

Monitoring Program (PDMP), where available,

Your assessment should include:

Facts About Buprenorphine

BUPRENORPHINE

Checklist for Prescribing Medication

for the Treatment of Opioid Use Disorder

1

Assess the need for treatment

For persons diagnosed with an opioid use

disorder,* first determine the severity of

patient’s substance use disorder. Then identify

any underlying or co-occurring diseases or

conditions, the effect of opioid use on the

patient’s physical and psychological

functioning, and the outcomes of past

treatment episodes.
A physical examination that focuses on

physical findings related to addiction and

its complications.

Laboratory testing to assess recent opioid

use and to screen for use of other drugs.

Useful tests include a urine drug screen or

other toxicology screen, urine test for

alcohol (ethyl glucuronide), liver enzymes,

serum bilirubin, serum creatinine, as well

as tests for hepatitis B and C and HIV.

Providers should not delay treatment

initiation while awaiting lab results.

to detect unreported use of other

medications, such as sedative-hypnotics or

alcohol, that may interact adversely with

the treatment medications.

Educate the patient about how the medication

works and the associated risks and benefits;

obtain informed consent; and educate on

overdose prevention.

2

3

There is potential for relapse & overdose on

discontinuation of the medication. Patients

should be educated about the effects of using

opioids and other drugs while taking the

prescribed medication and the potential for

overdose if opioid use is resumed after tolerance

is lost.

Evaluate the need for medically managed

withdrawal from opioids

Those starting buprenorphine must be in a state

of withdrawal.

4

Address co-occurring disorders

5

All medications for the treatment of the opioid use

disorder may be prescribed as part of a

comprehensive individualized treatment plan that

includes counseling and other psychosocial

therapies, as well as social support through

participation in mutual-help programs.

Have an integrated treatment approach to meet

the substance use, medical and mental health, and

social needs of a patient.

Integrate pharmacologic and nonpharmacologic

therapies

6

Refer patients for higher levels of care, if

necessary

Bup reno rphine Quick S ta r t Guide | page 2

*See The Criteria from American Psychiatric Association (2013). Diagnostic

and Statistical Manual of Mental Disorders, Fifth Edition,. Washington, DC,

American Psychiatric Association, page 541.

Refer the patient for more intensive or specialized

services if office-based treatment with

buprenorphine or naltrexone is not effective, or the

clinician does not have the resources to meet a

particular patient’s needs. Providers can find

programs in their areas or throughout the United

States by using SAMHSA’s Behavioral Health

Treatment Services Locator at

www.findtreatment.samhsa.gov.

Induction Considerations

Long acting opioids, such as methadone, require at least 48-72 hours since last use

before initiating buprenorphine.

Short acting opioids (for example, heroin) require approximately 12 hours since last use

for sufficient withdrawal to occur in order to safely initiate treatment. Some opioid such

as fentanyl may require greater than 12 hours.

Clinical presentation should guide this decision as individual presentations will vary.

The dose of buprenorphine depends on the severity of withdrawal symptoms, and the

history of last opioid use (see flowchart in appendix for dosing advice).
Bup reno rphine Quick S ta r t Guide | page 3

The risk with initiating

buprenorphine too soon is

that buprenorphine has a

very high affinity for the mu

receptor and will displace

any other opioid on the

receptor, thereby causing

precipitated opioid

withdrawal.

Precipitated withdrawal can occur due to

replacement of full opioid receptor

agonist (heroin, fentanyl, or morphine)

with a partial agonist that binds with a

higher affinity (Buprenorphine).

Symptoms are similar to opiate

withdrawal.

Avoid by ensuring adequate withdrawal

before induction (COWS > 12; Fentanyl

may require higher COWS score and

lower initial dosing), starting

Buprenorphine at a lower dose

(2.0mg/0.5 mg), and reassessing more

frequently.

Should precipitated withdrawal occur,

treatment includes:

Providing support and information to

the patient

Management of acute symptoms

Avoid the use of benzodiazepines

Encourage the patient to try induction

again soon

Buprenorphine Side Effects

Buprenorphine’s side effects may be

less intense than those of full

agonists. Otherwise, they resemble

those of other mu-opioid agonists.

Possible side effects include: Oral

numbness, constipation, tongue pain,

oral mucosal erythema, vomiting,

intoxication, disturbance in attention,

palpitations, insomnia, opioid

withdrawal syndrome, sweating, and

blurred vision

Buprenorphine FDA labels list all

potential side effects

Determine Withdrawal

Objective withdrawal signs help establish physical dependence

Information on Precipitated Withdrawal

Bup reno rphine Quick S ta r t Guide | page 3

Co-prescribing of overdose reversal agents

such as Naloxone is also recommended
Bup reno rphine Bup reno rphine Bup reno rphine Quick S ta r t S ta r t S ta r t Guide | page 43

Maintenance Therapy

Check PDMP regularly to

ensure prescriptions are

filled, and to check other

prescriptions.

Order urine drug testing

(UDT) and consider

confirmatory testing for

unexpected results. UDT

can facilitate open

communication to change

behavior.

Assess for readiness for

extended take-home

dosing

Goal = once-daily dosing, no

withdrawal between doses.

Ideally, average dosing does

not exceed 16 mg/4 mg (See

flowchart in appendix)

Psychosocial Therapies

Although people often

focus on the role of

medications in MAT,

counseling and

behavioral therapies that

address psychological

and social needs may also

be included in treatment.

To find treatment, please

consult

www.findtreatment.gov.

Diversion

Diversion is defined as the

unauthorized rerouting or

misappropriation of

prescription medication to

someone other than for

whom it was intended

(including sharing or selling

a prescribed medication);

m isuse includes taking

medication in a manner, by

route or by dose, other than

prescribed.

Early in treatment patients should be seen often, and

less frequently only when the provider determines

they are doing well.

Providers should inquire about safe and locked

storage of medications to avoid theft or inadvertent

use, especially by children. Patients must agree to safe

storage of their medication. Counsel patients about

acquiring locked devices and avoiding storage in parts

of the home frequented by visitors.

Limit medication supply. Prescribe an appropriate

amount of medications until the next visit. Do not

routinely provide an additional supply “just in case.”

Use buprenorphine/naloxone combination products

when medically indicated. Reserve daily

buprenorphine monoproducts for pregnant patients

and/or patients who could not afford treatment if the

combination product were required.

Counsel patients on taking their medication as

instructed and not sharing medication.

Ensure that the patient understands the practice’s

treatment agreement and prescription policies.

Providers can utilize the sample treatment agreement

in SAMHSA’s TIP 63, Page 3-78. A treatment agreement

and other documentation are clear about policies

regarding number of doses in each prescription, refills,

and rules on “lost” prescriptions.

Directly observe ingestion randomly when diversion is

suspected.

Providers should order random urine drug testing to

check for other drugs and for metabolites of

buprenorphine. Providers should also consider

periodic point of care testing.

Doctors should schedule unannounced pill/film

counts. Periodically ask patients to bring in their

medication containers for a pill/film count.

Providers should make inquiries with the Prescription

Drug Monitoring program in their state to ensure that

prescriptions are filled appropriately and to detect

prescriptions from other providers.

Early in treatment, providers can ask the patient to

sign a release of information for a trusted community

support individual, such as a family member or

spouse, for the purpose of communicating treatment

concerns including diversion.

How can providers minimize diversion risk?

1.

2.

3.

4.

5.

6.

7.

8.

9.

10.

11.
What should I do if a patient diverts or misuses the medication?

Misuse or diversion doesn’t mean automatic discharge from the practice.

Document and describe the misuse and diversion incident. Also document the clinical thinking

that supports the clinical response, which should be aimed at minimizing future risk of diversion

while still supporting the use of MAT.

Strongly consider smaller supplies of medication and supervised dosing.

Treatment structure may need to be altered, including more frequent appointments, supervised

administration, and increased psychosocial support.

When directly observed doses in the office are not practical, short prescription time spans can

be considered.

In situations where diversion is detected, open communication with the patient is critical.

Providers may consider injectable and implantable buprenorphine to reduce diversion, once

verified.

Bup reno rphine Bup reno rphine Bup reno rphine Quick S ta r t S ta r t S ta r t Guide | page 35

Disclaimer: Nothing in this document constitutes an indirect or direct endorsement by the Substance Abuse and Mental Health

Services Administration (SAMHSA) or the U.S. Department of Health and Human Services (HHS) of any non-federal entity’s

products, services, or policies and any reference to a non-federal entity’s products, services, or policies should not be construed

as such. No official support of or endorsement by SAMHSA or HHS for the opinions, resources, and medications described is

intended to be or should be inferred. The information presented in this document should not be considered medical advice and

is not a substitute for individualized patient or client care and treatment decisions.
Bup reno rphine Bup reno rphine Quick S ta r t S ta r t Guide | page 63

Algorithm for In-Office Induction (for home induction prescriptions may be given)

Initial Assessment

Day One (Induction)

Maintenance

Day Two

Important Considerations: Buprenorphine/Naloxone Dosing

Tablets/film may be split if

necessary

May take up to 10 min to

dissolve completely (no

talking, smoking, or

swallowing at this time)

Absorption better with

moistened mouth

samhsa.gov

Bup reno rphine Quick S ta r t Guide | page 6