Treat patients with opioid use disorder on-shift.

Protocol Quick Links:

Buprenorphine Hospital Quick Start Protocol

Bup Quick Start Flowchart


  • Any prescriber can order Bup in the hospital, even without an x-waiver.
  • Bup is a high-affinity, partial agonist opioid that is safe and highly effective for treating opioid use disorder.
  • If the patient is stable on methadone or prefers methadone, recommend continuation of methadone as first-line treatment.

*Complicating Factors

Buprenorphine Dosing

  • Either Bup or Bup/Nx (buprenorphine/naloxone) films or tab sublingual (SL) are OK.
  • If unable to take oral/SL, try Bup 0.3mg IV/IM.
  • OK to start with lower initial dose: Bup 2-4mg SL. – Total initial daily dose above 16mg may increase duration of action beyond 24 hrs.
  • Bup SL onset 15 min, peak 1 hr, steady state 7 days
  • May dose qday or if co-exisiting chronic pain split dosing TID/QID.

**Diagnosing Opioid Withdrawal

Subjective: Patient reports feeling “bad” due to withdrawal (nausea, stomach cramps, body aches, restlessness, hot and cold, stuffy nose)

Objective: [at least one] restlessness, sweating, rhinorrhea, dilated pupils, watery eyes, tachycardia, yawning, goose bumps, vomiting, diarrhea, tremor.

Typical withdrawal onset:
≥ 12 hrs after short acting opioid
≥ 24 hrs after long acting opioid
≥ 48 hrs after methadone (can be >72 hrs)

If unsure, use COWS (clinical opioid withdrawal scale). Start if COWS ≥ 8 AND one objective sign.

If Completed Withdrawal: Typically >72 hrs since last short-acting opioid, may be longer for methadone. Start Bup 4mg q4h prn cravings, usual dose 16-32mg/day. Subsequent days, OK to decrease frequency to qday

Patient Not Yet in Withdrawal: Use Home Start

Guidance for patients starting buprenorphine outside hospitals or clinics

  • Rapid Self-Starts – For people with higher opioid tolerance, experience with withdrawal or experience with buprenorphine
  • Gentle Self-Starts – For people with lower opioid tolerance, major medical issues, or less withdrawal experience

Opioid Analgesics

  • Pause opioid pain relievers when starting Bup.
  • OK to introduce opioid pain relievers after Bup is started for breakthrough pain. Do not use methadone with Bup.

Supportive Medications

Can be used as needed while waiting for withdrawal or during induction process.


  • Bup monoproduct or Bup/Nx OK in pregnancy.
  • Consider referencing buprenorphine in pregnancy guide.

Medications at discharge

Prescribe bup up to 14 days with Naloxone in hand

If no X-waiver: Use loading dose up to 32mg for 
long effect and give rapid follow up.

If X-waiver: Check CURES (not required in Emergency Department if ≤7-day prescription) prescribe sufficient Bup/Nx until follow-up.

Download printable .PDF of the protocol