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    Buprenorphine (Suboxone) Initiation for Opioid Use Disorder Patients

    Toxicology

    Last Updated Nov 17, 2018
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    Context

    • For patients with Opioid Use Disorder (OUD – addiction) who are in withdrawal and wanting help.
    • ED sees more of these patients than anyone else and we have the opportunity to intervene to initiate opioid agonist therapy with buprenorphine (Suboxone), which has the best evidence for saving lives and treating OUD.
    • Initiate in ED and refer to outpatient opioid agonist therapy prescriber/addictions clinic.
    • Risk of precipitating withdrawal with starting Suboxone when patient is not in full withdrawal.

    Recommended Treatment

    • Suboxone (buprenorphine) = buprenorphine /naloxone combination pill available in doses of 8mg/2mg and 2mg/0.5mg.
    • Suboxone initiation based on Clinical Opiate Withdrawal Scale (COWS). Please see: sample instruction sheet from Island Health.
    • The goal is to err on the side of being conservative and waiting as long as possible to start treatment to ensure patient is in withdrawal.
      • Ideally at least 8-10 hours after last use and when Cows score is at least 12.
      • If in doubt can give ½ of 2mg tab sl to test.

    Criteria For Hospital Admission

    • Observation unit useful to allow time to be in full withdrawal in order to start medication.

    Criteria For Close Observation And/or Consult

    • Once treatment has started and Suboxone is given, the patient COWS is repeated q 1h and medication is given until patient symptoms controlled.
    • Routine monitoring applies.

    Criteria For Safe Discharge Home

    • Patient has take-home naloxone kit, information on addiction medicine clinic, and enough Suboxone to last until first appointment.
    • If being discharged with take-home or take-away Suboxone, should be sure that the patient is not consuming large quantities of alcohol or benzodiazepines.  Suboxone on its own will not respiratory suppression, but there have been case reports of it possibly facilitating it in combination with alcohol and benzos.
    • See: Suboxone Self Start Instructions for Patients (source: Island Health).

    Quality Of Evidence?

    Justification

    Clinical Expert Review; RCTs

    High

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