• Assess for and address other use disorders and withdrawal syndromes.  
• Consider screening for sexually transmitted infections, including HIV, hepatitis C virus, syphilis, gonorrhea, and chlamydia. Consider linkage to PrEP as indicated. 

• Ensure pain and OUD symptoms are adequately controlled to prevent patient-directed discharge. 
• Patients experience significant anxiety about pain. 
  • A caring, supportive approach is essential.  
  • Create a plan with the patient for what to do if their pain is not well controlled. 
• Discussion of MOUD treatment options is more effective when pain and withdrawal are well-managed. 
• Provide multimodal pain management and maximize non-opioid pain interventions. Consider acetaminophen, gabapentinoids, alpha-2 agonists, muscle relaxants, local anesthetics, pain dose ketamine, regional anesthesia, and nonpharmacologic approaches. See Adjunct Medications. 
• Treat acute pain with opioids, when indicated.  
  • This does not worsen OUD. 
  • Patients with opioid tolerance may require significantly higher than typical doses of opioid analgesics to adequately control pain. See Opioid Dosing for Acute Pain in Patients with OUD and High Opioid Tolerance. 
  • Short acting, full agonist opioids can be used in combination with buprenorphine using this initiation method. 

• Urine drug screening (UDS) is not needed to initiate treatment for OUD.    
  • UDS only indicates whether certain substances or their byproducts are present within a set detection window. It does not measure impairment, gauge severity of SUD, explain behavior, or rule out significant use when negative. It works best when it answers a specific clinical question and is part of a broader treatment plan.
  • False-positives and false-negatives are not uncommon.
  • If UDS is performed for clinical reasons, obtain informed consent. 
  • A positive UDS should not be conflated with child abuse or neglect.  
    • Support the dyad by providing evidence-based treatment and patient education. 
    • In Washington state, substance use alone does not constitute a mandatory report to Child Protective Services.

• Use shared decision-making to guide medication selection.
• Methadone
  • Methadone is a long-acting, full opioid agonist with high receptor affinity.
    • It suppresses opioid withdrawal symptoms and cravings by maintaining stable receptor occupancy throughout the day. 
    • Its high receptor affinity can block the effect of short-acting opioids, like fentanyl, unless overridden with high doses.
    • Initiation doses are sub-therapeutic and dose escalation must be done slowly, as the sedating effects peak before the half-life stabilizes. 
  • Review drug-drug interactions before starting methadone.  
  • For more information about methadone, see the linked methadone protocols. 
• Buprenorphine 
  • Buprenorphine is a long-acting, partial opioid agonist with high receptor affinity.
    • It suppresses opioid withdrawal symptoms and cravings by maintaining stable receptor occupancy throughout the day. 
    • It produces a lesser effect on the mu-opioid receptor compared to full agonists. 
    • It has a ceiling effect on respiratory drive, making respiratory depression unlikely even at very high doses. Combining it with other CNS depressants may increase risk.
    • Its exceptionally high receptor affinity causes it to displace full agonists and block their effects.
      • Because of this, full-dose buprenorphine can precipitate severe, acute withdrawal if initiated when full agonist opioids still occupy the receptor; patients must therefore either be in sufficient withdrawal before the first full dose, or use an up-titration method, as in this protocol, to slowly transition onto buprenorphine.
• The uptitration method is preferred in pregnancy because it avoids withdrawal.
  • This method creates a "ramp" onto buprenorphine over several days while maintaining a full agonist opioid. 
  • This gradual escalation avoids the sudden receptor displacement that causes precipitated withdrawal in standard buprenorphine initiation methods and eliminates the need for the patient to be in withdrawal beforehand. 
  • After achieving a therapeutic dose, typically 8 mg TID, the full agonist is stopped or tapered down.
  • Withdrawal should be avoided in pregnancy, as it leads to fetal distress and increases risk of preterm labor and other pregnancy and delivery complications.
  • This method is more successful when completed inpatient, as the complicated dosing regimen is difficult for patients to complete. However, if the patient does not agree to inpatient care, offering a home initiation is appropriate.
• Maintenance dose
  • 8 mg TID-QID is recommended as an initial prescription while the patient stabilizes.
  • A daily dose of at least 16-32 mg buprenorphine is considered effective for most patients. 
  • Buprenorphine metabolizes faster later in pregnancy. Patients may require higher doses or more frequent dosing (up to every 6 hours) to maintain therapeutic levels.
  • Buprenorphine has a ceiling effect on respiratory drive, making respiratory depression unlikely even at very high doses. Combining it with other CNS depressants may increase risk.
  • Higher doses do not increase the risk of neonatal opioid withdrawal and are safe for breastfeeding.
  • Doses lower than 16 mg daily may be considered for patients with lower opioid tolerance. Tolerance may be lower if the patient:   
    • Does not need to use fentanyl multiple times daily to prevent/manage withdrawal.  
    • Is using an opioid that is less potent than fentanyl (e.g., oxycodone).  
    • Is an adolescent.  
    • Has been abstinent from opioids long enough that tolerance has meaningfully declined. This timeframe is variable in people who chronically use fentanyl, since it accumulates in adipose tissue and has slow clearance over several weeks or longer.
• Formulation
  • “Buprenorphine” in this protocol refers to either the monoproduct (buprenorphine, brand name Subutex) or combination product (buprenorphine/naloxone, brand name Suboxone or Zubsolv). 
  • These formulations work interchangeably. Both are appropriate and effective.
  • The monoproduct may require prior authorization and may only be covered by insurance in cases of pregnancy or adverse reaction to naloxone.  
  • Naloxone is present in the combination product solely to deter intravenous misuse. Naloxone is not well absorbed sublingually but is rapidly absorbed intravenously. Intravenous use precipitates withdrawal.

If a patient continues to use extra-medical opioids while on buprenorphine, a higher dose may be indicated to better manage OUD symptoms. Continued substance use is not a reason to stop treatment or consider it a failure. Buprenorphine significantly reduces the risk of all-cause mortality for people with OUD, even with continued extra-medical opioid use.     

• For more information on buprenorphine in pregnancy, see Medications for OUD in Pregnancy & Postpartum.
• Adolescents: 
  • Consent: In Washington State, youth age 13+ can consent to OUD treatment without parental consent (RCW 71.34.530).  
  • Consider expert consultation for pregnant adolescents. 
  • A sample uptitration dosing schedule is described in the Inpatient Buprenorphine Initiation in Pregnancy protocol under Special Populations. This can be adapted for home initiation.

• Polysubstance use is not a contraindication to MOUD. 
• Stimulant use 
  • Stimulant withdrawal can cause sedation and hypersomnia that may be confused with over-sedation from methadone.  See Assessment. 
  • Stimulant intoxication can mimic symptoms of opioid withdrawal, including dilated pupils, sweating, agitation, hypertension, tachycardia. Symptoms specific to opioid withdrawal include runny nose, yawning, and piloerection.
• Address withdrawal syndromes and other use disorders.  
  • Benzodiazepine and alcohol withdrawal must be monitored carefully and treated aggressively.  
  • Increase monitoring if treating withdrawal syndromes with other CNS depressants.  
  • Buprenorphine does not treat other withdrawal syndromes. 

This section is focused on buprenorphine uptitration at home. If the patient will be admitted or is initiating methadone, see the appropriate linked protocol.

• Buprenorphine films are preferred over tablets because they allow for more precise, reliable dosing with the very small starting doses required for this method.
  • To get the very small doses required, the manufacturer doses must be divided. In the inpatient setting, this is done by pharmacy.
  • Films can be cut into more accurate, reproducible fractions (e.g., a 2 mg film cut into quarters for ~0.5 mg doses), whereas tablets crumble and fracture unevenly.
  • The drug is evenly dispersed throughout a film, so each cut piece delivers a predictable proportion of the dose; split tablet fragments may deliver inconsistent amounts.
  • Films adhere to the mucosa and dissolve in place, supporting more consistent sublingual absorption.
• Buprenorphine is administered sublingually. Ensure proper dosing technique: 
  • Keep the film under the tongue until fully dissolved. 
  • Do not talk, eat, drink, or smoke while it is dissolving. 
  • Do not eat or drink for 15 minutes after. 
  • To prevent tooth decay, rinse mouth with water 30 minutes after it has fully dissolved. 
• If available, a peer or similar role can help by sitting with the patient throughout medication administration to remind them of proper technique.

This section is focused on buprenorphine uptitration at home. If the patient will be admitted or is initiating methadone, see the appropriate linked protocol.

• Ensure the maintenance buprenorphine prescription provided lasts at least until the scheduled follow up appointment.
  • If there is no appointment scheduled, provide at least 7-14 days to allow time for the patient to secure an appointment.
  • Consider a longer duration in areas with access challenges.
• Prescribe adjunct medications for withdrawal.
  • Patients commonly need adjunct medications to manage withdrawal symptoms until they stabilize on the medication.
  • Prescription duration should be at least 7 days.
• Ensure the patient is discharged with naloxone in hand.  
  • In Washington, emergency departments are required to dispense naloxone to patients with OUD or those otherwise at risk of opioid overdose, in compliance with 2SSB 5195.

• For shared decision-making resources to educate patients on MOUD options, see: https://scalanw.org/moud 
• For buprenorphine uptitration at home, educate the patient on:
  • Proper buprenorphine dosing technique
    • Buprenorphine must be taken under the tongue to receive the benefit of the medication.
    • Keep the film under the tongue until it is fully dissolved.
    • Do not talk, eat, drink, or smoke while it is dissolving.
    • Do not eat or drink for 15 minutes after.
    • To prevent tooth decay, rinse mouth with water 30 minutes after it has fully dissolved.
  • Overdose prevention 
    • Ensure the patient and their support system understand when and how to use naloxone.
    • The risks of change in use patterns, which can alter tolerance and increase risk of opioid overdose.
    • The risk of respiratory depression when combining buprenorphine with CNS depressants (“sedatives” or “downers”), including alcohol.
    • See Discharge Instructions for additional overdose prevention strategies.
• Neonatal opioid withdrawal syndrome (NOWS) 
  • The baby may experience NOWS shortly after delivery. This is expected when taking buprenorphine, is treatable, and does not cause long-term health issues. It is much riskier to leave OUD untreated.
  • Encourage the patient to discuss their MOUD treatment with their OB provider. The OB provider can help them plan for labor, delivery, and postpartum, including pain and NOWS management.

• When possible, connect patients with social work, care navigation, and/or peer support to strengthen linkage to care.
• Help the patient schedule an appointment or inform them of walk-in availability, where available.
  • 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.  
  • Hospitals not enrolled in ScalaNW may contact known sites directly or use the Washington Recovery Helpline to locate providers.
  • Ensure the patient is aware of the date, time and location for follow up.  
• If there will be a delay in follow up care, the patient can contact the Washington Telebuprenorphine Program at (206) 289-0287 for a virtual visit for a bridge prescription.