Suboxone Induction
Embedded Files
Inclusion Criteria
Inclusion Criteria
History of Opiate Use Disorder
Remote OUD but at risk for relapse (just released from Jail) are still eligible
Cooperative patient willing to undergo induction
Must be either Asymptomatic OR in Active Withdrawal
Urine Preg, LFTs, Urine Tox Ordered in Main ED
Exclusion Criteria
Exclusion Criteria
Currently on Methadone
High Risk for Precipitate Withdrawal
Have apparent evidence of liver failure
Currently intoxicated with opiates (this patient should be given a Narcan Pre-Pack, discharged and may re-present when they start to have withdrawal symptoms to be considered for induction)
Currently with toxidrome involving non-opiate intoxicants
The Goal
The goal here is to get a patient on a therapuetic dose of Buprenorphine without causing a precipitate withdrawal. Because of the different pharmacokinetics of various opiates there are two pathways for this protocol, a standard and a slow and low pathway.
The Pathways
Standard Pathway
Patients who use short acting opiates (heroin, oxy etc) and last dose was OVER 12 hours ago
Patients using Fentanyl LESS than 10 pills a day and last dose OVER 24 hours ago
Patients using Fentanyl MORE than 10 pills a day and last dose OVER 48 hours ago
LOW and SLOW Pathway
Patients using Fentanyl LESS than 10 Pills a day and last dose LESS than 24 hours ago
Patients using Fentanyl MORE than 10 Pills a day and last dose LESS than 48 hours ago
Standard Pathway
Standard Pathway
Document COWS Score on Arrival
IF COWS < 12 Give Buprenorphine 4 mg (two suboxone tablets)
IF COWS > 12 Give Buprenorphine 6 mg (three suboxone tablets)
Repeat Buprenorphine 2 mg - 4 mg EVERY 1-2 Hours as NEEDED for withdrawal symptoms (Any COWS > 0)
MAX Dose Buprenorphine 24 mg in 24 hours.
Supportive Adjunct Medications to be ordered as PRN
Ondansetron 8 mg PO/IV Q8hr PRN
Clonidine 0.1mg-0.3mg PO/IV Q8hr PRN
Hydroxazine 50 mg PO Q8h PRN
Lomotil one tab BID
If COWS Increases by 3 or more after first dose of Buprenorphine, this is likely precipitated withdrawal. If severe can treat with Ketamine, or High Affinity Opiate such as Fentanyl or Hydromorphone
Slow and Low Pathway
Slow and Low Pathway
Document COWS Score on Arrival and Q1 Hour after
IF COWS < 12 Hold off on any Buprenorphine, continue adjunctive medications below
IF COWS > 12 Give Buprenorphine 1 mg (One half a suboxone tablet)
Repeat Buprenorphine 1 mg - 2 mg EVERY 1-2 Hours as NEEDED for withdrawal symptoms (Any COWS > 0)
MAX Dose Buprenorphine 24 mg in 24 hours.
Supportive Adjunct Medications to be ordered as PRN
Ondansetron 8 mg PO/IV Q8hr PRN
Clonidine 0.1mg-0.3mg PO/IV Q8hr PRN
Hydroxazine 50 mg PO Q8h PRN
Lomotil one tab BID
If COWS Increases by 3 or more after first dose of Buprenorphine, this is likely precipitated withdrawal. If severe can treat with Ketamine, or High Affinity Opiate such as Fentanyl or Hydromorphone
Disposition
Discharge
Discharge
Symptoms of withdrawal controlled
Write Rx for three to seven day supply of daily dose needed to control withdrawal symptoms
Can write Rx for adjunct medications as above
BHE can provide resources to patient for local Buprenorphine Clinics
Admit to Hospital
Admit to Hospital
Symptomatic Precipitate Withdrawal Requiring Full dose Opiates (may need transfer to center that does methadone - Denver health)
Unstable Vitals, Altered Mental Status
Page updated
Google Sites
Report abuse