Implement low-barrier, rapid-access, addiction treatment while you’re on-shift/on-service.
- 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.
- 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
- 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.
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.