Buprenorphine Quick Start Guide: Hospital

For the most current information on this topic, please see Management of Opioid Use Disorder.

Use this stepwise approach to identify candidates for buprenorphine treatment of opioid use disorder and get them started quickly and safely.

  1. Get registered to prescribe buprenorphine.
    • The prescription for buprenorphine to be taken between discharge and the first visit to the outpatient prescriber must be written by a prescriber with a buprenorphine waiver.  If there is no waived prescriber, the patient can return to the hospital clinic or emergency department to have the dose administered by a non-waived prescriber for up to a total of 72 hours.
    • Prescribers can submit a Notification of Intent to prescribe buprenorphine for opioid use disorder without getting special training.  After the application is approved, receipt of a special unique identifying number (X-designation) will allow prescribing of buprenorphine.  For details on this process, see https://www.samhsa.gov/medication-assisted-treatment/become-buprenorphine-waivered-practitioner.
  2. Identify buprenorphine candidates (e.g., people with ≥4 DSM-5 criteria for opioid use disorder).  See our FAQ, Management of Opioid Use Disorder for details.
  3. Educate the patient about buprenorphine.  Have a respectful discussion of treatment options.  Explain that:
    • buprenorphine is not trading one addiction for another; it is a tool to help regain function.
    • opioid use disorder 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 such as benzodiazepines.
  4. Initiate buprenorphine/naloxone.  (Initiation dosing for patients in the community may differ.  See our outpatient quick start guide for more information.)
    • Discontinue opioids when no longer needed for pain and the patient is stable enough to tolerate withdrawal.   Our FAQ, Management of Opioid Use Disorder, provides usual intervals between opioid discontinuation and onset of withdrawal. 
    • Start induction when the patient is clearly experiencing withdrawal.  If naloxone has been given, generally wait two hours to assess withdrawal.
    • Target a buprenorphine dose that improves withdrawal without causing sedation or euphoria.  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/
  5. Prescribe buprenorphine/naloxone to continue at home (waived prescriber).  
    • Example:  Buprenorphine/naloxone 8 mg/2 mg tabs or film.  One sublingually twice daily.  Dispense XX (enough to last until outpatient appointment).
    • Prescribe rescue naloxone.
    • Patients should call the prescriber if they if they feel sleepy after their dose, or if the prescribed dose feels inadequate.
  6. Schedule follow-up:
    • Maintain a list of local buprenorphine prescribers who will see new patients promptly, and pharmacies that carry buprenorphine/naloxone.
    • Discharge patient to a specific buprenorphine prescriber for stabilization and maintenance within 72 hours.
    • Send discharge information (e.g., treatment course, medications administered, medications prescribed).

Additional resources:

 

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