SUBOXONE® (buprenorphine and naloxone)

Medication Assisted Treatment (MAT)

If you want to quit opioids, you are in the right place. Below is an overview of our Suboxone treatment programs. There are many different treatment options from rapid detox to long-term maintenance.

What happens during the first visit?

We will assess the severity of your opioid use disorder together.

At least two of the following should be observed within a 12-month period:1

  1. Opioids are often taken in larger amounts or over a longer period than was intended.
  2. There is a persistent desire or unsuccessful efforts to cut down or control opioid use.
  3. A great deal of time is spent in activities necessary to obtain the opioid, use the opioid, or recover from its effects.
  4. Craving, or a strong desire or urge to use opioids.
  5. Recurrent opioid use resulting in a failure to fulfill major role obligations at work, school, or home.
  6. Continued opioid use despite having persistent or recurrent social or interpersonal problems caused or exacerbated by the effects of opioids.
  7. Important social, occupational, or recreational activities are given up or reduced because of opioid use.
  8. Recurrent opioid use in situations in which it is physically hazardous.
  9. Continued opioid use despite knowledge of having a persistent or recurrent physical or psychological problem that is likely to have been caused or exacerbated by the substance.
  10. *Exhibits tolerance.
  11. *Exhibits withdrawal.

*These criteria not considered to be met for those individuals taking opioids solely under appropriate medical supervision.

We will discuss your substance use history.

  • All drugs used, including alcohol, nicotine, benzodiazepines
  • Age and amount of first use, current use
  • Any periods of abstinence
  • Treatment history
  • Goals
  • Concerns

We will review your lab work together and order tests if needed.

  • Complete blood count
  • Electrolytes
  • Kidney panel
  • Liver panel
  • Hepatitis A/B/C serologies
  • STI panel (including HIV)
  • Urine drug test

We will review reasons not to start Suboxone due to the harm that it could cause.

  • Pregnancy
  • Severe liver disease
  • Severe respiratory disease
  • Acute alcohol intoxication

Starting the medication.

The process of starting Suboxone is called induction. You can be at our office to get started, or you can do this at home.

When to stop taking opioids.

Short-acting: 12-24 hours before first dose. This includes heroin, codeine, hydromorphone (Dilaudid), hydrocodone/acetaminophen (Vicodin), morphine, oxycodone, oxycodone/acetaminophen (Percocet).

Long-acting: 36 hours before first dose

Methadone: >48 hours before first dose

Why do some people get sick when taking Suboxone?

Suboxone is stronger and stickier to the target receptor than other opioids… so if you have anything else in your system, Suboxone will remove it and you will experience withdrawal symptoms.

Symptoms: Increased heart rate, sweating, agitation, diarrhea, tremor, unease, restlessness, tearing, runny nose, vomiting, goose flesh.

Treatment: Usually reversible with higher doses of Suboxone. Sometimes symptomatic treatment with clonidine or loperamide.

Prevention: Ensure adequate withdrawal symptoms are present before induction. Consider starting at a lower dose (2.0mg/0.5mg).

Day 1

Stop all opioids for 12-36 hours. You will feel lousy, like you have the flu.

Before using the self assessment worksheet, you should feel at least three of the following:

  • very restless, can’t sit still
  • twitching, tremors, or shaking
  • enlarged pupils
  • bad chills or sweating
  • heavy yawning
  • joint and bone aches
  • runny nose, tears in your eyes
  • goose flesh / bumps
  • cramps, nausea, vomiting, or diarrhea
  • anxious or irritable


Fill out the Subjective Opiate Withdrawal Scale (SOWS) in your workbook. Your score should be >17 before taking your first dose of Suboxone.

Once you are ready, take 4 mg of Suboxone under the tongue. Do not swallow it. Suboxone does not work if swallowed.

Wait an hour.

  • If you feel fine, do not take any more medication today. Record your total for the day in the workbook.
  • If you still have withdrawal symptoms, take a second 4 mg dose under the tongue.
  • If you feel worse than when you started, you might have precipitated withdrawal. Call us so we can help you.


Wait 1-2 hours.

  • If you feel fine, do not take any more medication today. Record your total for the day in the workbook.
  • If you continue to have withdrawal symptoms, take a third 4 mg dose under the tongue.


Wait 1-2 hours.

  • If you feel fine, do not take any more medication today. Record your total for the day in the workbook.
  • If you continue to have withdrawal symptoms, take a fourth 4 mg dose under the tongue.


Wait 1-2 hours.

  • If you continue to have withdrawal symptoms, call us.
  • Do not take more than 16 mg (4 doses) on day 1.

Day 2

  • If you feel fine, take the same dose this morning.
  • If you feel some withdrawal symptoms, add 4 mg.
  • Later in the day, if you still feel withdrawal, take another 4 mg.
  • Call us if you have any questions or concerns.

Day 3

  • If you felt good at the end of day 2, take the same dose this morning.
  • If you feel some withdrawal symptoms, add 4 mg.
  • If you feel too tired, groggy, or over-sedated, lower the dose by 2 to 4 mg.
  • If you feel too tired, groggy, or over-sedated AFTER taking this morning’s dose, consider splitting tomorrow’s dose into a morning and afternoon dose.
  • If withdrawal symptoms are gone, consider induction complete.
  • Do not take more than 32 mg in a day!

Day 4

  • Take yesterday’s total dose as the ongoing dose.
  • Day 4 is a good time for a check-in appointment.

Stabilization

You may need more or less medication, depending on how you feel overall, if you still have cravings, or if you are still using. At this point, you should discuss any dose adjustments with your doctor. If you need to increase your dose, you should not change it by more than 4 mg per day.

Maintenance

  • Once-daily dosing.
  • No withdrawal symptoms between doses.
  • Urine drug testing is not used punitively but to facilitate open communication.

Related

Coming soon:

  • Suboxone rapid detox plan
  • Suboxone pain management plan

References

  1. Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition,. Washington, DC, American Psychiatric Association page 541.