Overcoming Acute Roadblocks During Suboxone Induction

April 15, 2021

How can we as providers help patients succeed in their buprenorphine/naloxone (B/N) induction?

For many patients starting on buprenorphine/naloxone (Suboxone), this is an “old hat” for them. They have either been getting B/N (buprenorphine/naloxone) “off the street” or have been on B/N in the past. These patients have experience making this transition and usually require little instruction or support. They probably could even teach us about a successful start!

For other patients who are taking prescribed or non-prescribed full agonist opioids (like oxycodone, fentanyl, or heroin) and have never been on B/N, they might need more “hand holding” in making this transition.

For these patients, there are three key ways to help them succeed:

1-Set clear expectations of the induction process

2-Ensure adequate time has passed before beginning B/N

3-Check in with the patient immediately after to ensure success & navigate any obstacles

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1: Set clear expectations of the induction process

Studies have shown that home inductions are just as effective and safe as office inductions and allow patients to go through withdrawal in the comfort of their own home rather than in a less comfortable office setting. (1,2)

The key to a successful induction is ensuring that the patient is in the appropriate level of withdrawal before starting B/N. 

If they have full agonist opioids on their receptors when B/N (a partial agonist) is introduced, the B/N will push all those full agonists off their receptors at once, causing a precipitated withdrawal that feels like “the flu on speed”-- a much worse feeling than if they allow the withdrawal to happen naturally over time.

Thus, the patient needs to feel fairly uncomfortable before starting B/N, and it is our job to set this expectation for them.

Before starting B/N, the patient should feel at least 3 of the following symptoms:

  • Restlessness    
  • Goose pimples
  • Heavy yawning           
  • Stomach cramps
  • Body aches           
  • Nausea/vomiting
  • Runny nose           
  • Enlarged pupils

If patients want more guidance to ensure they are in moderate to severe (ie appropriate) withdrawal before starting B/N, you can give them a SOWS (self-opioid withdrawal scale): (3)

If their SOWS withdrawal score is 17 or more, they are ready to start. 

If their SOWS withdrawal score is less than 17, they should check their score again in 1-3 hours and wait until it is 17 or more before starting.

Another good rule of thumb to tell patients: “Wait until you are feeling very uncomfortable and you think you are ready to take your Suboxone. THEN- set your alarm for one more hour and take the Suboxone after that.”

HOT TIP:

→ Bottom line: We need to communicate to patients that they should feel VERY uncomfortable (“dope sick”) before starting Suboxone.

Additionally, we can help our patients get through this withdrawal period by:

  • Encourage patients to go through withdrawal at NIGHT so they are not uncomfortable throughout the day when they are awake.
  • Offer to prescribe comfort medications to help them manage their withdrawal. This is NOT necessary but might make the transition period easier.

Comfort meds for opioid withdrawal symptoms:

HTN/anxiety/restless legs: Clonidine 0.1mg po TID. 

Diarrhea: Loperamide 4mg po with first loose stool, then 2mg for each subsequent loose stool. Max 24 mg/day

Pain/myalgias: Ibuprofen 600mg po q6 hrs or acetaminophen up to 1000mg po q8 hrs

Abdominal cramping: Dicyclomine 20mg po q4 hrs

Nausea: Ondansetron 4-8mg po q8hrs. 

Insomnia: Trazodone 50-100mg po qhs.

2: Ensure adequate time has passed before beginning B/N

Clarify with the patient which opioid they have been taking and provide guidance on when to start B/N based on this:

Short acting (heroin, Percocet, oxycodone, Vicodin): > 8-12 hours

Long-acting (fentanyl, Oxycontin, MS Contin): > 24 hours

Methadone: > 48- 72 hours 

Once they have reached this time AND feel very uncomfortable (as previously described), they can begin the induction process.

  • Walk them through the induction protocol. Below is a sample induction protocol that I helped develop after reviewing several different protocols. There is no single induction protocol that is “right” or “wrong,” and most versions are slight variations of each other. The overall goal should be to gradually transition patients from full agonist opioid to Buprenorphine while minimizing uncomfortable withdrawal symptoms.
  • Provide a handout that the patient can refer to.
  • Conduct “teach back” with the patient: have them repeat back to you what you just explained so you can ensure they understood the protocol correctly.
  • Remind them they can call you/your nurse at any time to ask questions.

General buprenorphine/naloxone (Suboxone) Induction Protocol:

  • Take 4 mg tablet (half of the usual 8 mg tabs/film)
  • If you tolerate it without worsening withdrawal, take another 4 mg 1-2 hours later
  • If tolerate it without withdrawal, take another 4 mg 6 hours later
  • DO NOT go above 12 mg on the first day
  • The next day- take 1.5 tabs/films (12 mg); if still feeling withdrawal 4 hours later, take ½ tab/film (do not exceed a total of 2 tabs/films on day two)
  • Keep taking this dose (1.5-2 tabs/films/day; ie 12- 16 mg Buprenorphine/day) until you follow up with your B/N- prescribing provider.

Also remind patients how to take B/N:

-NEVER swallow it or it won’t work you will experience withdrawal symptoms; it must dissolve under tongue for 15 minutes 

-Counsel on “Rule of 15”:

  1. No drinking/eating/smoking 15 minutes before taking (if your mouth is dry, take a sip of water before taking the buprenorphine strips or tablets)
  2. Let the buprenorphine strip or tablet dissolve under tongue for 15 minutes (don’t talk while it is dissolving)
  3. No drinking/eating/smoking 15 minutes after taking

3: Check in with the patient immediately after induction to ensure success & navigate any obstacles (4,5,6)

To do this, ask your patient when they plan to take their last full agonist opioid and figure out when they will likely be going through the induction process.

Let your patient know that you or your nurse will outreach to them immediately after their induction.

This will put their mind at ease that someone will be available to support them and provide further guidance as needed.

Use this time to check in about the induction process, how it went, and any obstacles they encountered along the way. Check in about when they took their last opioid, how long they waited before taking the B/N, what their symptoms felt like before they began, how they felt after starting the B/N, and how they followed the protocol.

One common pitfall: Taking B/N too soon causing precipitating withdrawal

When the patient takes their first dose of buprenorphine/naloxone after being in moderate-severe withdrawal, they should feel BETTER, not worse. If they feel worse, that means they likely did not wait long enough and caused precipitated withdrawal.

How to respond to precipitated withdrawal

1-Preferred method: Have the patient take more buprenorphine/naloxone (Suboxone) to override the withdrawal.

For example, if they initially took 2 mg of buprenorphine/naloxone and they then felt worse, tell them to take/repeat 2 mg doses of buprenorphine/naloxone every 1-2 hours until they feel better (never to exceed 12-16 mg on the first day). 

Note that some patients may resist the continued induction and return to full agonist opioid use as a method to self-medicate their precipitated withdrawal.

Other options

2) If the patient is scared and wants to just stop, put the induction on hold and have them try again at another time, but ensure they wait a much longer period of time between their last full agonist opioid and starting the buprenorphine/naloxone.

3) For patients with repeated failures at home induction (due to taking their B/N too soon), there is a new concept known as microdosing that you can try. Because it is new, it does NOT have an evidence-base to support it. However, it is anecdotally proving to be a novel way to help support patients make the transition from full agonist opioids to B/N.

The premise behind microdosing is that the patient continues to take their full agonist opioid while starting with small doses of buprenorphine/naloxone. They then gradually increase their B/N dose and then come off their full agonist opioid and hence experience minimal withdrawal symptoms during the transition. Here is one sample protocol. Note that the patient will need to cut the films/tabs provided to take the small doses of B/N.

Outpatient protocol for microdosing

Modeled on Becker W (Becker/Frank/Edens, Ann Int Med letter 7/2020)

Day, Bup/nx (only list bup dose), Other opioid

1, 0.5mg bid, usual

2, 1mg bid, usual

3, 1mg tid, usual

4, 2mg tid, less than usual, if possible

5, 4mg tid, none

6, 8mg bid, none

7, 16mg daily, none

In conclusion, when it comes to the B/N induction, our goal should be to make the transition from full agonist opioids to B/N is as easy as possible for our patients. Providing clear expectations from the beginning, an outlined induction protocol that they understand and can explain back, and follow-up provider outreach can support patients and set them up for a successful entry into (hopefully!) long-term recovery.

Bicycle Health

Bicycle Health is a telehealth company that provides buprenorphine/naloxone (Suboxone) for patients with opioid dependence and addiction across the U.S. We provide patients with robust support during the buprenorphine/naloxone induction process with clear protocols and clinical support services. We also provide ongoing care to maximize patients’ success in their recovery journey.

To learn more about the success rates and safety of Bicycle Health’s telemedicine addiction treatment in comparison to other common treatment options, call us at (844) 943-2514 or schedule an appointment here.

Photo Courtesy of Gunter Valda on Unsplash.

About the Author

Randi Sokol, MD, MPH, MMedEd

Randi Sokol, MD, MPH, MMedEd, is an Assistant Professor at the Tufts Family Medicine Residency Program and Instructor at Harvard Medical School. She is Board Certified in both Family Medicine and Addiction Medicine. She earned her B.A. at the University of Pennsylvania, her Medical Degree and Masters in Public Health from Tulane University, completed Family Medicine Residency at UC-Davis, and earned a Masters in Medical Education through the University of Dundee.

Citations

(1) Center for Substance Abuse Treatment (CSAT). Clinical Guidelines for the Use of Buprenorphine in the Treatment of Opioid Addiction. Rockville: Substance Abuse and Mental Health Services Administration; 2004.

(2) Martin SA, Chiodo LM, Bosse JD, Wilson A. The Next Stage of Buprenorphine Care for Opioid Use Disorder. Ann Intern Med. 2018;169:628-635.

(3) Handelsman L, Cochrane K-J, Aronson M-J. et al . Two new rating scales for opiate withdrawal. Am J Drug Alcohol Abuse. 1987; 13 293-308

(4) Gunderson EW, Wang XQ, Fiellin DA., Bryan B., & Levin FR. Unobserved versus observed office buprenorphine/naloxone induction: A pilot randomized clinical trial. Addictive Behaviors. 2010; 35(5), 537–540.

(5) Lee JD, Vocci F, Fiellin DA. Unobserved “home” induction onto buprenorphine. J Addict Med. 2014;8:299-308.

(6) Martin SA, Chiodo LM, Bosse JD, Wilson A. The Next Stage of Buprenorphine Care for Opioid Use Disorder. Ann Intern Med. 2018;169:628-635.

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