A practical guide for buprenorphine initiation in the primary care setting

Article Figures & Data

TABLE 1

Buprenorphine formulations and indications

Generic name and administration route	Brand name	Dose formulations	US Food and Drug Administration indication
Buprenorphine hydrochloride for intravenous or intramuscular administration	Buprenex injection	0.3 mg/mL	Acute moderate-to-severe pain
Buprenorphine transdermal system	Butrans	5 μg/hour 7.5 μg/hour 10 μg/hour 15 μg/hour 20 μg/hour	Chronic pain
Buprenorphine buccal film	Belbuca	75 μg 150 μg 300 μg 450 μg 600 μg 750 μg 900 μg	Chronic pain
Buprenorphine extended-release injection for subcutaneous use	Sublocade	300 mg/1.5 mL monthly after induction for first 2 months 100 mg/0.5 mL maintenance dose monthly (can increase to 300 mg)	Opioid use disorder
Buprenorphine sublingual tablets	Subutex	2 mg 8 mg	Opioid use disorder
Buprenorphine/naloxone sublingual film	Suboxone	2 mg/0.5 mg 4 mg/1 mg 8 mg/2 mg 12 mg/3 mg	Opioid use disorder
Buprenorphine/naloxone sublingual tablets	Suboxone	2 mg/0.5 mg 8 mg/2 mg	Opioid use disorder
Buprenorphine/naloxone sublingual rapid-dissolve tablets	Zubsolv	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	Opioid use disorder

TABLE 2

Options for home buprenorphine induction

Day	Complex home induction	Simplified home induction	Precise induction (may be better suited for inpatient use)
1	Cut 2-mg buprenorphine/naloxone film into 4 pieces, take 1 piece every 6 hours	Cut 8-mg buprenorphine/naloxone film into 8 pieces, take 1 piece every 1–2 hours	150-μg buprenorphine buccal film every 3 hours for 8 doses
2	Cut 2-mg buprenorphine/naloxone film into 2 pieces, take 1 piece every 6 hours	Take 8-mg buprenorphine/naloxone film twice daily	450-μg buprenorphine buccal film every 6 hours for 2 doses; then 900-μg buprenorphine buccal film for 2 doses
3	Take 2-mg buprenorphine/naloxone film every 6 hours	Follow up with primary care physician	2-mg buprenorphine/naloxone film every 4 hours for 4 doses
4	Take 8-mg buprenorphine/naloxone film twice daily		8-mg buprenorphine/naloxone film 2 or 3 times per day
5	Follow up with primary care physician		Follow up with primary care physician

TABLE 3

Symptomatic management of opioid withdrawal

Symptom	Drug	Dose
Anxiety	Hydroxyzine	25–100 mg orally every 6–8 hours as needed (maximum 400 mg/day)
Anxiety	Lorazepam	1 mg every 4–6 hours as needed (maximum 6 mg/day)
Hypertension, tachycardia	Clonidine	0.1–0.2 mg every 6–8 hours, taper if given for > 7 days
Diarrhea	Loperamide	4 mg initial dose followed by 2 mg after each loose stool (maximum 16 mg/day)
Myalgias, arthralgias	Acetaminophen	1,000 mg every 6–8 hours
Myalgias, arthralgias	Ibuprofen	600 mg every 6 hours for up to 7 days (maximum 2,400 mg/day)
Nausea, vomiting	Ondansetron	4 mg every 6 hours as needed (maximum 16 mg/day)
Insomnia	Trazodone	25–100 mg nightly (maximum 300 mg)
Muscle cramps	Cyclobenzaprine	5–10 mg every 8 hours as needed (maximum 30 mg/day)
Gastrointestinal cramps	Dicyclomine	10–20 mg every 6–8 hours as needed (maximum 160 mg/day)