Adolescent buprenorphine initiation at home (ages 13+)

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Adolescent buprenorphine initiation at home (ages 13+)

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Considerations

Starting buprenorphine at home is a good option for patients who are not in withdrawal while in the ED.

Buprenorphine is FDA approved for ages 16 and older. Its use in those under 16 is off label but widely considered safe and effective. 

In Washington State, patients 13 or older can be treated for substance use disorder without parent/guardian notification or consent.

Consider expert consultation for complicating factors: 

  • Allergy or sensitivity 
  • Severe respiratory compromise 
  • Chronic use of long-acting opioids (e.g., methadone or Oxycontin) 

Protocol

Document icon Adolescent buprenorphine initiation at home (ages 13+) Flowchart of Adolescent Buprenorphine Home Initiation

Related Protocols

Document icon Adjunct Medication

Patient Handouts

Document icon Adolescent home initiation handout (Ages 13+)

Additional Clinical Guidance

  • Opioid use disorder (OUD) is a treatable health condition. It is best treated with methadone or buprenorphine.
  • Buprenorphine and methadone are life-saving medications for OUD that reduce the risk of all-cause mortality and overdose death by over 50%.
  • Recovery often requires multiple treatment attempts. A repeat encounter is not a treatment failure, but an opportunity to reinitiate potentially life-saving medication.
  • If patients continue to use other opioids while on methadone or buprenorphine, a higher dose may be needed to manage their symptoms. Therapeutic dosing should be guided by adequate management of withdrawal and cravings. 
  • Opioid withdrawal is excruciating. Without swift and adequate intervention, patients may self-direct discharge and be at risk for overdose.
  • Patients with OUD are highly stigmatized. Stigma prevents people from seeking care and worsens health outcomes. Providers should challenge biases to provide compassionate, evidence-based care. 
  • Adolescents may have better outcomes if a guardian is involved in their care. If the patient consents, a dependable adult can help manage medications and symptoms.
     
Document icon ScalaNW_Adolescent-Buprenorphine-Home-Guidance

AssessmentAccordion Icon

  • Consider screening for abuse, assault, mental health comorbidities, HIV, HCV, and STIs. 

LabsAccordion Icon

  • Drug testing is not necessary to initiate treatment for OUD. 
  • If drug testing is performed for clinical reasons, obtain informed consent. 

PharmacotherapyAccordion Icon

  • Buprenorphine is a partial opioid agonist that helps to minimize withdrawal and lessen opioid cravings.
  • Buprenorphine has minimal effect on respiratory drive, making respiratory depression unlikely even at higher doses.
  • Buprenorphine has high receptor affinity, allowing it to out-compete other opioids. This competitive binding can precipitate withdrawal because it will rapidly replace the more potent opioid that is present. This is why patients should be in withdrawal before starting buprenorphine with this method. 
  • Competitive binding also reduces overdose risk by blocking other opioids. Even a single dose provides protection for at least 24 hours, during the high-risk period after discharge.
  • Doses should be adjusted based on symptoms— if the patient has ongoing withdrawal symptoms or cravings to use, a dose increase should be considered.

Special populationsAccordion Icon

  • Consider expert consultation for pregnant adolescents.

Polysubstance useAccordion Icon

  • Stimulant intoxication can falsely elevate the COWS score. 
  • Buprenorphine administration may unmask symptoms of stimulant intoxication. 
  • Polysubstance use is never a contraindication for initiating buprenorphine.
     

Discharge planningAccordion Icon

  • Help the patient schedule a follow-up appointment. Hospitals enrolled in ScalaNW can call the 24/7 appointment scheduling line and receive a confirmed date, time, and location for MOUD follow up appointment during the 10-minute phone call.
    • For hospitals not enrolled in ScalaNW, the Washington Recovery Helpline MOUD Locator (online or at 1-866-789-1511) is a useful resource for finding OUD treatment in Washington.
  • Ensure the patient is provided with a buprenorphine prescription to last until their scheduled appointment. If an appointment is not scheduled, provide at least 7-14 days to allow time to secure an appointment.
    • Patients can call the UW Telebuprenorphine line if they run out of medication prior to their follow up appointment: (206) 289-0287.
  • Patients commonly need adjunct medications to control withdrawal symptoms until they stabilize on the medication. Provide scripts to last at least 7 days.
  • Write down the earliest time they can take their first buprenorphine dose (12-24 hours after their last use). 
  • In Washington, emergency departments are required to dispense naloxone to patients with OUD or others who are at risk of opioid overdose, in compliance with SB5195. Ensure patient is discharged with naloxone in hand.
  • If possible, connect patient with supports such as social workers, care navigators, or peers to improve patient experience and linkage to care.
     

Patient EducationAccordion Icon

  • Recommend that an adult or other supportive, responsible person help the patient with dosing at home, if possible. 
  • Discuss the risk of precipitated withdrawal. 
    • Because buprenorphine is a partial agonist with high receptor affinity, it can cause sudden, severe withdrawal if it is taken (at typical doses) before the patient is in moderate withdrawal. 
    • If this happens, additional doses of buprenorphine can alleviate withdrawal by providing more activation of the opioid receptors. Adjunct medications should also be taken.
  • Instruct the patient to assess their symptoms before starting buprenorphine. The worse they feel when they start the medication, the lower the risk of precipitated withdrawal. They should have at least 3 symptoms of withdrawal prior to starting the medication. At least one of these should be an objective sign (i.e., measurable or visible to someone other than the patient).
    • Restlessness 
    • Yawning 
    • Runny nose 
    • Big pupils 
    • Watery eyes 
    • No appetite 
    • Stomach cramps 
    • Body aches 
    • Shaking 
    • Twitching 
    • Sweats 
    • Chills 
    • Goosebumps 
    • Nausea or vomiting 
    • Diarrhea 
  • Explain the use of each adjunct medication, and that they can be used throughout the initiation process.
  • Advise the patient on proper administration: 
    • Buprenorphine must be administered under the tongue, or it will not absorb properly.
    • Drinking water prior to administration can help it dissolve faster. 
    • It can take 5-10 minutes for the medication to fully absorb. Avoid eating, drinking, smoking, or talking during this time, and for 15 minutes after.
    • After 15 minutes has passed, a strong mint can help with the aftertaste, which many find unpleasant.
    • To prevent oral decay, rinse mouth with water 30 minutes after administration.
  • Recommend taking their dose around the same time each day.
  • Warn that respiratory depression can occur if buprenorphine is taken with other CNS depressants. Patients should avoid using other drugs, drinking more than their usual amount of alcohol, or taking higher doses of CNS-depressing medications.
  • Advise the patient to continue buprenorphine even if they return to using other opioids.
  • Educate on overdose prevention strategies (see Discharge Instructions).
  • Changes in use patterns can alter tolerance and increase risk of opioid overdose.
     

Discharge Instructions

Directions for starting buprenorphine at home

  •  How to take the medicine correctly:
    • Put the buprenorphine under your tongue. 
    • Do not swallow it! It will not work if swallowed. 
    • Keep the medication there until it is fully dissolved. 
    • Drinking water beforehand can help it dissolve faster. 
    • Do not talk, eat, drink, or smoke while it is dissolving. 
    • Do not eat or drink for 15 minutes after. After 15 minutes have passed, a breath mint or candy can help get rid of the taste. 
    • After 30 minutes, rinse your mouth with water. This helps prevent tooth decay.
  • Day 1
    • Wait until you have at least 3 symptoms of withdrawal (listed below). 
      • This usually happens 12-24 hours after you last use opioids. The longer you wait, the better. If you take it too soon, your withdrawal could suddenly get much worse. 
      • You can take other medications as prescribed to treat symptoms while you wait. 
    • Take 1 tablet/film (4 mg) under your tongue. 
    • Wait 30-60 minutes. 
      • If you suddenly feel very sick, you may have taken the medication too soon. Take another 8 mg (2 tablets/films) and have someone drive you to the ER. Taking more buprenorphine will help you feel better by providing more opioid effect.
      • If you only feel a little worse, the same, or better, continue to the next step. 
    • If you still have withdrawal symptoms, take another tablet/film (4 mg) once every 30-60 minutes until you feel better. Do not take more than 4 tablets/films (16 mg) on Day 1.
  • Day 2
    • Take half of the total dose needed on Day 1. 
    • Wait 8-12 hours. 
    • Take the other half of the Day 1 dose. 
    • Repeat this daily until your follow-up appointment.

Information about buprenorphine

  • Buprenorphine is a safe and effective medication used to treat opioid use disorder (OUD). 
  • Buprenorphine helps people with OUD break the cycle of use and withdrawal, feel more stable, and focus on other parts of their lives so they can recover. 
  • When used as prescribed, buprenorphine significantly lowers the risk of opioid overdose and death.
  • There are two kinds of buprenorphine. Buprenorphine-naloxone also contains naloxone. Naloxone is not absorbed when the medication is taken as directed (under the tongue). If the medication is injected, however, the naloxone will be absorbed and can cause severe opioid withdrawal.
  • There is no limit to how long a person can take buprenorphine. Most people should be on the medication for at least 6 months, and many benefit from it for years.
  • Side effects may occur but are typically mild and improve over time. These can include constipation, sweating, headache, dizziness, trouble sleeping, nausea, and sleepiness. If these occur, notify your health care provider, nurse, or pharmacist. 
  • A common side effect of buprenorphine and other opioid medications is constipation. To prevent constipation: stay hydrated, eat plenty of fiber, and start taking an over-the-counter stool softener. If you do not have a bowel movement in over 24-48 hours, try an over-the-counter laxative. Talk to the pharmacist to help choose the best one for you.
  • Over time, your body will adjust to buprenorphine. If you stop taking it suddenly, you will feel withdrawal symptoms within a few days.

CAUTION

  • Continue taking your regular buprenorphine dose, even if you feel better. Stopping may cause withdrawal and cravings. Your risk of overdose will be much higher if you use opioids without being on this medication. 
  • An overdose can happen if you take buprenorphine with alcohol or other “downers,” like Xanax and other pills that make you sleepy.
  • Do not drink more than your usual amount of alcohol while starting buprenorphine. 
  • Do not drive when you first start buprenorphine because it may slow your reaction time. Wait until you know how it affects you. 

  • Changes in opioid use patterns can alter your tolerance and increase your risk of opioid overdose. If you use other opioids, take steps to lower the risk—carry naloxone, never use alone, or call the Never Use Alone lifeline (877-696-1996).

    Buprenorphine dose and time taken 
    ________mg @___:____

Tips to prevent overdose if you use drugs
Using street drugs is risky. You can reduce your risk of dying from an opioid overdose with the following strategies:  

  • Always have naloxone (Narcan).
    • Naloxone is a medication that reverses opioid overdose. It is safe to use on anyone you think may be experiencing an overdose.
    • Tell others you have naloxone, where it is, and when to use it. 
    • Visit stopoverdose.org or talk to your provider, nurse, or pharmacist to learn more or get more naloxone.
  • Know the signs of opioid overdose and how to respond. 
    • If someone is unresponsive or has unusual or no breathing, call 911 and give them naloxone and rescue breaths. 
  • Try not to use alone.
    • If you are alone, use a confidential service like neverusealone.com. This peer-led service will send someone to help if you stop responding during a chat or phone call.
  • Start low & go slow.
    • You can't know the full contents or strength of drugs. If you use, start with a small amount to see how it affects you. 
    • Be extra cautious if you have low tolerance (for example, after not using for a while). If you decide to use more, slowly increase in small amounts.
  • Watch and wait before next person uses. 
    • If you’re with a group of people, take turns to see how the drug is affecting people. Someone needs to be able to ask for help. 
  • Avoid mixing drugs.
    • Mixing drugs increases your risk. If you use multiple drugs, try to use one at a time and use less of each. 
  • Get treatment with methadone or buprenorphine.
    • These medications, if taken as directed, lower the risk of death by over 50%. 
    • If you need help finding a treatment provider, call the Washington Recovery Helpline at 866-789-1511 or go to warecoveryhelpline.org. 
       
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Additional Resources

References

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