Treat patients with opioid use disorder on-shift.


  • This guidance is for the ED. We advocate for the continuation & initiation of bup in inpatient and outpatient settings. Algorithms vary based on clinical scenario.
  • We encourage shared decision making with patients for dosing.
  • Any prescriber can order bup in the ED/hospital. It can be prescribed as medication for opioid use disorder by any clinician with an active Drug Enforcement Agency license that includes Schedule III medications.
  • 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.

Opioid Withdrawal

  • At least one clear objective sign (prefer ≥ 2): Tachycardia, mydriasis, yawning, rhinorrhea, vomiting, diarrhea, piloerection. Ask the patient if they are in bad withdrawal and if they feel ready to start bup. If they feel their withdrawal is mild, it is too soon.
  • If unsure, use COWS (clinical opioid withdrawal scale). Start if COWS ≥ 8 AND objective signs.Typical withdrawal onset >12 hours after last short acting opioid use (excluding fentanyl); variable after last use of fentanyl or methadone (may be >72 hours).

Start protocol may vary for complicating factors:

  • Altered mental status, delirium, intoxication
  • Severe acute pain, trauma or planned large surgeries
  • Organ failure or other severe medical illness  (decompensated heart failure, respiratory distress, hemodynamically unstable, etc.)
  • Recent methadone use
  • Minimal opioid tolerance (consider lower dosing)
  • Most people who use fentanyl do well with starts following this guide. For fentanyl specific initiation questions, see Fentanyl FAQ.

If patient has already completed withdrawal (no longer symptomatic withdrawal, often >72 hrs from last use of opioids) and wants to start bup:

  • Give bup 8 mg SL q6h PRN cravings, usual dose 16-32mg/day.
  • After first day, consolidate dosing to daily.

Buprenorphine Dosing

  • Either bup or bup/nx (buprenorphine/naloxone) SL films or tab are OK. If chronic pain, may split dose TID-QID.
  • Pause opioid pain relievers when starting Bup. OK to introduce opioid pain relievers after bup is started if patient has acute pain.
  • Bup monoproduct or bup/nx OK in pregnancy. See Buprenorphine Quick Start in Pregnancy.
  • If unable to take oral/SL, try Bup 0.3mg IV/IM.
  • OK to start with lower initial dose: Bup 2-4mg SL.
  • Bup SL onset 15 min, peak 1 hr, steady state 7 days.

Treatment of precipitated withdrawal

  • Precipitated withdrawal is a sudden, significant worsening of withdrawal after bup or full antagonist (e.g., naloxone).
  • Administer additional 16 mg SL bup immediately. Reassess in 30-60 minutes. If continued distress remains: Repeat 8-16 mg bup SL.

If precipitated withdrawal not resolved by bup:

  • Consider alpha-2 agonists (clonidine or dexmedetomidine), antipsychotics (e.g., haloperidol), cautious use of benzodiazepines (e.g., 1-2 mg PO lorazepam x 1), high potency opioid (e.g., fentanyl 100-200 mcg IV q30 or infusion), or ketamine (0.3 mg/kg IV slow push q30 minutes or continuous infusion until calm).
  • Once withdrawal is managed, continue daily bup dose.

Patient Not Yet in Withdrawal: Use Non-Facility Start

Guidance for patients starting buprenorphine outside hospitals or clinics, see Buprenorphine Self-Starts.


  • Prescribe sufficient bup/nx until follow-up: e.g., buprenorphine/naloxone 8/2 mg SL films 2-4 films qday #32-64, 0 refills (may Rx more PRN). Notes to pharmacy: bill Medi-Cal FFS, ICD 10 F11.20, X DEA # ___.
  • An X-waiver is no longer needed to prescribe bup.
  • Dispense naloxone from the ED (not just prescribed): e.g., naloxone 4 mg IN spray #2.
  • Document Opioid Withdrawal and/or Opioid Use Disorder as a diagnosis.