Management of Opioid Use Disorder
modified February 2025
Opioid use disorder (OUD) is “a problematic pattern of opioid use leading to clinically significant impairment or distress.”2 Medications to treat OUD prevent withdrawal (methadone, buprenorphine), decrease illicit opioid use, reduce criminal activity, improve social functioning, increase treatment retention, and reduce risk of overdose death.4,9 The chart below covers common clinical questions about approved medications for OUD, with a focus on buprenorphine/naloxone. COVID-related considerations are included. Advise having naloxone or nalmefene (US) on hand; US labeling now advises discussion of an opioid reversal agent with patients being treated with medications for OUD.12
Question |
Answer/Pertinent Information |
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How can I identify patients with opioid use disorder? |
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What approved pharmacologic treatment options are available for opioid use disorder? |
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How does pharmacotherapy work in the treatment of opioid use disorder? |
Buprenorphine and Buprenorphine/Naloxone
Pure mu opioid agonists (e.g., methadone, morphine slow-release [Kadian])
Naltrexone
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How do I identify patients who may be candidates for medications to treat opioid use disorder? |
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What are the pros and cons of the pharmacotherapy options for opioid use disorder? |
Pros |
Cons |
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Buprenorphine/naloxone |
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Methadone |
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Naltrexone |
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Buprenorphine implant (Probuphine [Canada]) |
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Long-acting buprenorphine injection (Brixadi [US]) |
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Long-acting buprenorphine injection (Sublocade) |
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Morphine slow release (Kadian [Canada]) |
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Hydromorphone injection (Hydromorphone HP) |
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Is there any reason to use sublingual buprenorphine monotherapy vs a buprenorphine/naloxone product? |
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What buprenorphine products are available in the US for treatment of opioid use disorder? |
Product |
Available Dosage Strengths |
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Sublocade (buprenorphine) depot injection |
300 mg or 100 mg injection |
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Brixadi (buprenorphine) depot injection |
weekly: 8 mg, 16 mg, 24 mg, 32 mg |
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Suboxone (buprenorphine/naloxone) sublingual film, generics |
2 mg/0.5 mg; 4 mg/1 mg; 8 mg/2 mg; 12 mg/3 mg |
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Suboxone (buprenorphine/naloxone) sublingual tablet, (generic only; brand no longer available) |
2 mg/0.5 mg; 8 mg/2 mg |
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Subutex (buprenorphine sublingual tablets) (generic only; brand no longer available) |
2 mg; 8 mg |
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Zubsolv (buprenorphine/naloxone) sublingual tablets |
0.7 mg/0.18 mg; 1.4 mg/0.36 mg; 2.9 mg/0.71 mg; 5.7 mg/1.4 mg; 8.6 mg/2.1 mg; 11.4 mg/2.9 mg |
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Are there differences among the available transmucosal US buprenorphine products? |
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What buprenorphine products are available in Canada for treatment of opioid use disorder? |
Product |
Available Dosage Strengths and Cost (wholesale) |
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Suboxone (buprenorphine/naloxone) sublingual tablet, generic |
2 mg/0.5 mg: $43.25 for 30 tabs (generic) 8 mg/2 mg: $76.63 for 30 tabs (generic) 12 mg/3 mg: $234.71 for 30 tabs (brand) 16 mg/4 mg: $312.94 for 30 tabs (brand) |
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Suboxone (buprenorphine/naloxone) film |
2 mg/0.5 mg: $86.51 for 30 4 mg/1 mg: $119.53 for 30 8 mg/2 mg: $153.25 for 30 12 mg/3 mg: $229.88 for 30 |
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Sublocade (buprenorphine) extended-release injection |
300 mg or 100 mg injection |
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Probuphine (buprenorphine) implant |
320 mg total in four implantable rods |
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For women who are pregnant, single-ingredient buprenorphine (Subutex) is available through Health Canada’s Special Access Programme.18 |
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How is sublingual buprenorphine generally dosed for opioid use disorder? |
Dosing presented here may differ from product labeling. Induction protocols vary. Dosing should be individualized.4
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Is there a limit as to how long a patient can use buprenorphine for opioid use disorder? |
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What adjunctive nonpharmacologic treatment should be considered? |
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How can I identify patients who may be misusing their buprenorphine or methadone, or taking nonprescribed substances? |
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Who can prescribe buprenorphine for opioid use disorder in the US? |
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Who can prescribe buprenorphine for opioid use disorder in Canada? |
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What are some practical considerations for opioid use disorder patients admitted to the hospital? |
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How should acute pain be treated in patients with opioid use disorder? |
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- Wholesale acquisition cost: US medication pricing by Elsevier, accessed September 2023.
--Continue to the next section for a Buprenorphine Quick Start Guide--
Buprenorphine Quick Start Guide
Use this stepwise approach to identify candidates for buprenorphine treatment of OUD and get them started quickly and safely. This guide is based on our FAQ, Management of Opioid Use Disorder(above), and SAMHSA’s Treatment Improvement Protocol, Medications for Opioid Use Disorder (https://store.samhsa.gov/sites/default/files/pep21-02-01-002.pdf), which you can consult for additional information (e.g., buprenorphine products available, drug interactions, use in special populations).
- Identify buprenorphine candidates. Candidates are people with moderate-to-severe OUD and physical dependence (withdrawal symptoms when trying to quit). A validated screening tool that can help to identify opioid misuse in patients taking opioids for chronic pain is the COMM (Current Opioid Misuse Measure) available at: https://www.mdcalc.com/calc/10428/current-opioid-misuse-measure-comm.
- Educate the patient about buprenorphine. Explain that:
- buprenorphine is not trading one addiction for another; it is a tool to help regain function.
- OUD is a chronic condition. Buprenorphine may reduce risk of relapse and can be continued as long as they benefit.
- stopping buprenorphine to use opioids poses a risk of overdose, as does using buprenorphine with alcohol or sedatives (e.g., benzodiazepines).
- Initiate buprenorphine/naloxone in the office, hospital, or at home (for reliable patients):
- Prepare the practice site. Have naloxone or nalmefene (US) on-hand and a policy for handling allergic reactions or precipitating withdrawal. Educate staff about buprenorphine to get buy-in to ensure a supportive environment. Engage billing professionals.
- Prescribe (for outpatient induction) a sublingual buprenorphine/naloxone product. Example Rx: Buprenorphine/naloxone 2 mg/0.5 mg. Dispense #XX (enough for a few days, or #4 for in-office induction). No refills. Fill on [date]. Also prescribe naloxone or nalmefene (US) for home use.
- Discontinue opioids when no longer needed for pain and the patient is stable enough to tolerate withdrawal. Usual intervals between opioid discontinuation and onset of withdrawal are provided above in the FAQ, Management of Opioid Use Disorder.
- Start induction when the patient is experiencing clear signs of withdrawal (nalmefene [US] lasts longer than naloxone,39 but no specific guidance is available in the context of starting buprenorphine). If naloxone has been given (e.g., in the emergency department), generally wait two hours to assess withdrawal.
- Target a buprenorphine dose that improves withdrawal without causing sedation or euphoria.
- Outpatient clinic dosing example: Allow several hours for up-titration. Target a dose that improves withdrawal without causing sedation or euphoria (usual first-day total = 8 mg).
- Hospital/emergency department dosing example: Consider starting with 4 mg for Clinical Opiate Withdrawal Scale (COWS) ≥8, or 8 mg for COWS ≥13, with an additional 4 to 8 mg in 45 to 60 minutes, to a usual first-day total of 16 mg (range 12 to 24 mg).
- Patients not yet in withdrawal can be educated on initiating at home when they are in withdrawal. See: https://medicine.yale.edu/edbup/.
- Educate on withdrawal symptoms and proper sublingual use.
- Prescribe buprenorphine/naloxone or nalmefene (US) and rescue naloxone for home use after initiation.
- After outpatient/clinic induction, one suggested approach from SAMHSA is:
- The next day, the patient will take the same total dose they took on day 1, in one dose. After two hours, if they are experiencing withdrawal, they can take an additional 2 mg/0.5 mg tablet (or equivalent), repeated once in another two hours if needed.
- On days #3 and #4, they will take the same total dose they took the previous day, in one dose, with the potential for 2 additional doses, as above.
- Patients should call the prescriber if they reach a total daily dose of 16 mg/4 mg, or if they feel sleepy after their dose.
- After hospital/emergency department induction:
- Example discharge prescription: Buprenorphine/naloxone 8 mg/2 mg tabs or film. One sublingually twice daily. Dispense XX (enough to last until outpatient appointment).
- Patients should call the prescriber if they feel sleepy after their dose, or if the prescribed dose feels inadequate.
- After outpatient/clinic induction, one suggested approach from SAMHSA is:
- Follow up at least weekly (initially).
- Hospitals/emergency departments can maintain a list of local buprenorphine prescribers who will see new patients promptly, and pharmacies that carry buprenorphine/naloxone. Discharge the patient to a specific buprenorphine prescriber for stabilization and maintenance. Send discharge information (e.g., treatment course, medications administered, medications prescribed).
- At follow-up, check for misuse (e.g., check Prescription Drug Monitoring Program [PDMP], urine drug screen, pill count), side effects (e.g., sedation), and progress toward predetermined goals (First week goal might be symptom improvement without oversedation.).
Abbreviations: COWS = Clinical Opioid Withdrawal Scale; OTP = opioid treatment program; OUD = opioid use disorder; SAMHSA = Substance Abuse and Mental Health Services Administration
References
- NIDA. How effective are medications to treat opioid use disorder? National Institute on Drug Abuse website. December 3, 2021. https://nida.nih.gov/publications/research-reports/medications-to-treat-opioid-addiction/efficacy-medications-opioid-use-disorder. (Accessed February 3, 2023).
- CDC. Interactive training series for healthcare providers: applying CDC’s guideline for prescribing opioids. Module 5: assessing and addressing opioid use disorder. https://www.cdc.gov/drugoverdose/training/oud/accessible/index.html. (Accessed February 3, 2023).
- Soyka M. New developments in the management of opioid dependence: focus on sublingual buprenorphine-naloxone. Subst Abuse Rehabil. 2015 Jan 6;6:1-14.
- Substance Abuse and Mental Health Services Administration. Medications for opioid use disorder. Treatment Improvement Protocol (TIP) series 63. Publication No. PEP21-02-01-002. Rockville, MD: Substance Abuse and Mental Health Services Administration, July 2021. https://store.samhsa.gov/sites/default/files/pep21-02-01-002.pdf. (Accessed February 3, 2023).
- Product information forZubsolv. Orexo US. Morristown, NJ 07960. June 2022.
- SAMHSA. Removal of DATA waiver (X-waiver) requirement. September 18, 2023. https://www.samhsa.gov/medications-substance-use-disorders/removal-data-waiver-requirement. (Accessed February 5, 2023).
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Cite this document as follows: Clinical Resource, Management of Opioid Use Disorder. Pharmacist’s Letter/Pharmacy Technician’s Letter/Prescriber’s Letter. March 2023. [390303]