Starting sublingual buprenorphine MATOD therapy

Sublingual buprenorphine is available as a film (in combination with naloxone) or tablet preparation; see Preparations of buprenorphine for medication-assisted treatment of opioid dependence (MATOD) for a comparison of preparations.

When starting sublingual buprenorphine MATOD therapy for patients who have been using a short-acting opioid (eg heroin, morphine, oxycodone), wait until signs of opioid withdrawal are evident; then useVictoria Department of Health, 2021:

buprenorphine 4 mg sublingually, as a single dose. Review in 1 to 2 hours. If the first dose did not precipitate worsening of withdrawal, and cravings are present, repeat the dose. Increase the dose each day in 2 mg, 4 mg, or 8 mg increments to achieve a maintenance dose (usually 12 to 24 mg daily) within several days. Maximum daily dose is 32 mg. buprenorphine buprenorphine buprenorphine

During buprenorphine dose titration, monitor for signs of withdrawal and toxicity, and use of other opioids and nonprescribed drugs. If exacerbation of withdrawal occurs, seek specialist advice.

In patients with low opioid tolerance, consider using a lower starting dose of buprenorphine (eg 2 mg) and 2 mg increments for dose titration because this reduces the risk of respiratory suppression and precipitating marked withdrawal.