Medication-Assisted Treatment:

                      Buprenorphine/Naloxone
Peter LeMere PharmD. PGY1 Resident
 Medication-Assisted Treatment (MAT) Agents
  Buprenorphine products Methadone Naltrexone
Opioid antagonist (requires
Partial opioid agonist (ceiling
Mechanism of Full opioid agonist (risk of prolonged period of abstinence
effect), high affinity binding
Action sedation/euphoria) before starting to avoid induced
(blocks or displaces other opioids)
withdrawal)
SL film/tablet, buccal film, patch,
Formulations Oral solution, tablet Tablet, IM injection (monthly)
SUBQ injection (monthly)

Any provider can initiate/continue

Ordering/ No restrictions
inpatient therapy, but MUST be No restrictions
Prescribing (see next slides)
prescribed at specialty licensed clinics

Products co-formulated with

 Effective in alcohol use
naloxone (Suboxone®) are
 Long half-life (8-59 hrs) disorder
designed to prevent diversion.
Pearls  Causes QTc prolongation –  Do NOT use in severe liver
Naloxone has < 2% PO
monitor EKG before initiation dysfunction or acute
bioavailability, but if injected,
hepatitis
would act as full opioid antagonist
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 MAT Ordering vs. Prescribing

Inpatient Orders Outpatient Prescriptions

Methadone: prescribed
ANY provider caring for
at specialty licensed clinics
the patient can initiate
and/or continue methadone,
Buprenorphine and
buprenorphine products, or
Naltrexone: no restrictions
naltrexone

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Waller RC and Virva M, et al. Medication Assisted Treatment Guidelines for Opioid Use Disorders. MDCH 2014.
Cunningham C and Fishman M. The ASAM National Practice Guideline for the Use of Medications in the Treatment of Addiction Involving Opioid Use. Accessed September 2022.
 MAT Ordering vs. Prescribing

Inpatient Orders Outpatient Prescriptions

Methadone: prescribed
ANY provider caring for
at specialty licensed clinics
the patient can initiate
and/or continue methadone,
Buprenorphine and
buprenorphine products, or
Naltrexone: no restrictions
naltrexone

4
Waller RC and Virva M, et al. Medication Assisted Treatment Guidelines for Opioid Use Disorders. MDCH 2014.
Cunningham C and Fishman M. The ASAM National Practice Guideline for the Use of Medications in the Treatment of Addiction Involving Opioid Use. Accessed September 2022.
 Buprenorphine Prescribing: What is new?

• X-waiver no longer required to

prescribe buprenorphine products for
OUD
• All providers with DEA reg. permitted
As of December • Required training in development by
2022 SAMSHA & DEA --> June 2023

Department of Health and Human Services. Practice Guidelines for the Administration of Buprenorphine for Treating Opioid Use Disorder. Accessed September 2022.
Buprenorphine/Naloxone
Sublingual Film/Tablets

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 Inpatient Initiation Dosing Guidance

Day 1 Day 2 Maintenance

• Last opioid use > 6-12 hrs ago
• Patient in moderate
withdrawal
Give total daily
dose from Continue dose that
Give 2-4 mg abated withdrawal with
dose x 1 Day 1
review
 (MAX 32 mg/day, likely
Reassess in 2 hrs: Reassess in 2 hrs:
Withdrawal symptoms resolved? Withdrawal symptoms resolved?
target 8-16 mg/day)

Yes No Yes No

Give additional
Continue same Continue same Give additional 2-
2-4 mg dose
dose once daily dose once daily 4 mg doses PRN
(Day 1 MAX: 8
with review with review (Day 2 MAX: 16 mg)
mg)

Substance Abuse and Mental Health Services Administration. Buprenorphine Quick Start Guide. Accessed August 4, 2021.
Initial Dosing Considerations

2 mg
Patient is heavy fentanyl user and/or you are worried
about precipitated withdrawal*
*Due to extensive distribution into adipose tissue. Recommended
to start lower dose or wait longer (e.g., 24 hrs) before initiating

4 mg Most common initial dose

May be considered for patients initiating treatment

8 mg
in outpatient setting

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 Considerations for Acute Pain

Continue maintenance • Initiate short-acting opioid PRN

therapy

Divide daily dose of • Can consider TID dosing with likely increase in daily dose
buprenorphine BID • Take advantage of the short-acting analgesic properties

Less preferred:
Discontinue buprenorphine • Not recommended
and initiate opioid therapy
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Alford DP et al. Acute pain management for patients receiving maintenance methadone or buprenorphine therapy. Ann Intern Med 2006;144(2):127.
Restarting Therapy after Full Agonist Treatment
If therapy was stopped to treat acute pain with full agonists:
Wean full agonist to lowest tolerable dose
Completely stop full agonist for 12-24 hrs or until patient is in moderate
withdrawal
Give ½ of patient’s prior Suboxone® dose
After 2 hrs, give other ½ of patient’s prior Suboxone® dose

Patient will be back to previous dose of Suboxone® after 1 day

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Transitions of Care Recommendations

Admission

• Continue home buprenorphine dose

• Consult pharmacy if formulation not on formulary for
conversion
• Ex: Belbuca®

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Transitions of Care Recommendations

Discharge

• Ensure outpatient provider is comfortable

continuing MAT
• Family Medicine MAT Clinic to open April 2023
• No day-supply limit for buprenorphine
• Exception in 7-day prescribing limit
• 3-day rule for acute withdrawal no longer applies
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Questions?

Please contact:
Peter LeMere, PharmD.
• [email protected]
Jenna Gerhardt, PharmD.
• [email protected]
Chelsea Worstall, MD (Family Medicine)
• [email protected]
Iunia Dadarlat, MD (Psychiatry)
• [email protected]
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