Phases of Buprenorphine Treatment Buprenorphine maintenance can be divided into three phrases: induction, stabilization, and maintenance.

Induction :The goal of the induction is to find the patient's ideal daily dose of buprenorphine. The ideal daily dose minimizes both side effects and drug craving. For most opioid-dependent patients, the daily dose is 12 to 16 mg/day of the buprenorphine+ naloxone combination film or tablet. Induction usually takes 2 to 4 days to complete.

Stabilization:  Stabilization occurs in the 6 to 8 weeks following induction. This period begins when the patient is no longer experiencing withdrawal symptoms or intense cravings.The main goal of stabilization is to eliminate opioid use, as noted by patient reports and confirmed by urine drug testing.

Maintenance:  How to Conduct Buprenorphine Induction The maintenance phase lasts indefinitely (SAMHSA 2004). Long-term maintenance is recommended due to high relapse rates. For example, in one study of 255 individuals, approximately 87% relapsed at 3 months (Ling 2009). During this phase, the patient is maintained at a comfortable dose and reports minimal craving or side effects.

Standard Induction: Though pre-induction guidelines are slightly different for patients dependent on long- vs. short-acting opioids, the induction and dosing process is the same. Give the first dose when the patient is in mild to moderate opioid withdrawal on the COWS scale.; Induction Day 1:  Day 1, patients should be experiencing mild to moderate withdrawal. If using short acting opioids, patients must remain abstinent 12-24 hours before induction. Patients using long acting opioids should remain abstinent 36-72 hours prior to induction. Opioid-dependent patients should be inducted with a 4mg buprenorphine dose, observed for 1-2 hours, then given a second 4mg dose if withdrawal symptoms reappear. Some clinicians prefer to start with just a 2mg dose, which minimizes side effects (if any) and the chance of precipitated withdrawal. A maximum dose of 8-12mg is recommended for Day 1. It's helpful to allow a 2-4 hour window of office time on the first day of induction. You don't necessarily need to require patients to sit in the office the entire time.

Induction Day 2:  If a patient was over-medicated at the end of the first day, the dose can be decreased on Day 2. If the patient experiences withdrawal symptoms or cravings after taking a total of 8-12mg on Day 1, the dose should be increased on Day 2. Start on day 2 by giving the patient an initial 12-16mg dose (their Day 1 dose + 4mg). Then wait 1-2 hours and increase the dose in 2-4mg increments when withdrawal symptoms return. The total recommended dose for Day 2 should not exceed 16mg.

If withdrawal symptoms do not return within a few hours, you have established the patient's maintenance dose. Most patients' maintenance dose is between 12-16mg. Induction Day 3+ If the patient experiences withdrawal symptoms or cravings after taking a total of 16mg on Day 2, first assess whether the patient is taking the medication correctly (letting it dissolve under the tongue, not talking until it is dissolved, etc.). If so, then the dose should be increased on Day 3. Start day 3 by giving the patient an initial 18-20mg dose and increase dosing in the same manner as Day 2. The total recommended dose for Day 3 and after should not exceed 32mg/day, although very few patients will need a dose this high. Doses higher than this will not harm the patient but will do little to decrease patients' cravings, due to a ceiling effect. Patients who require a high dose should be re-evaluated at the time of induction and/or monitored for diversion.

Dealing with Complications During Induction Each practice should have a contingency plan in place in case of complications during induction even though it's rare it still is possible. Before starting your buprenorphine practice, you may want to establish a relationship with another buprenorphine provider in your area for consultation if problems arise. Severe adverse reactions to buprenorphine during induction are exceedingly rare - the most commonly reported adverse reaction is the development of precipitated opioid withdrawal. You can minimize the risk of precipitated opioid withdrawal by documenting that the patient is in opioid withdrawal prior to induction (using an opiate withdrawal scale instrument), and then dosing carefully. Patients should also be closely monitored between doses so that you can manage any side effects or adverse events that may occur. Additionally, complications can arise when patients are taking medications that interact with buprenorphine, such as benzodiazepines. Taking a thorough history and conducting urinalysis prior to induction should reduce the likelihood of such problems occurring. Managing Withdrawal Symptoms Patients' withdrawal symptoms during induction can be treated with non-opioid medications. These are sometimes called "comfort meds" and are most often needed by patients transferring from long-acting opioids: Anxiolytics (use very carefully and in limited quantities) Non-opioid pain relievers (NSAIDs or acetaminophen), while considering risks vs. benefits Antidiarrheal agents Antiemetics Antispasmodics