Standard Induction Protocol

Though pre-induction guidelines are slightly different for patients dependent on long- vs. short-acting opioids, the induction and dosing process is the same. Give the first dose when the patient is in mild to moderate opioid withdrawal on the COWS scale.

Induction Day 1

On Day 1, patients should be experiencing mild to moderate withdrawal. If using short acting opioids, patients must remain abstinent 12-24 hours before induction. Patients using long acting opioids should remain abstinent 36-72 hours prior to induction. Opioid-dependent patients should be inducted with a 4mg buprenorphine dose, observed for 1-2 hours, then given a second 4mg dose if withdrawal symptoms reappear. Some clinicians prefer to start with just a 2mg dose, which minimizes side effects (if any) and the chance of precipitated withdrawal. A maximum dose of 8-12mg is recommended for Day 1. It's helpful to allow a 2-4 hour window of office time on the first day of induction. You don't necessarily need to require patients to sit in the office the entire time.

Induction Day 2

If a patient was over-medicated at the end of the first day, the dose can be decreased on Day 2. If the patient experiences withdrawal symptoms or cravings after taking a total of 8-12mg on Day 1, the dose should be increased on Day 2. Start on day 2 by giving the patient an initial 12-16mg dose (their Day 1 dose + 4mg). Then wait 1-2 hours and increase the dose in 2-4mg increments when withdrawal symptoms return. The total recommended dose for Day 2 should not exceed 16mg.

If withdrawal symptoms do not return within a few hours, you have established the patient's maintenance dose. Most patients' maintenance dose is between 12-16mg.

Induction Day 3+

If the patient experiences withdrawal symptoms or cravings after taking a total of 16mg on Day 2, first assess whether the patient is taking the medication correctly (letting it dissolve under the tongue, not talking until it is dissolved, etc.). If so, then the dose should be increased on Day 3. Start day 3 by giving the patient an initial 18-20mg dose and increase dosing in the same manner as Day 2.

The total recommended dose for Day 3 and after should not exceed 32mg/day, although very few patients will need a dose this high. Doses higher than this will not harm the patient but will do little to decrease patients' cravings, due to a ceiling effect. Patients who require a high dose should be re-evaluated at the time of induction and/or monitored for diversion.

Related Resources: 
This PDF Document contains the Clinical Opioid Withdrawal Scale (COWS), a common instrument used to assess a patient's opioid withdrawal severity.
California Society of Addiction Medicine (CSAM)
Patient Handouts: