• Assess the Clinical Opiate Withdrawal Scale (COWS) score before administering buprenorphine. For this initiation approach, only administer buprenorphine if the patient has signs of withdrawal.
• Reassess vitals, COWS, and subjective experience of withdrawal within 30 minutes of buprenorphine administration. 

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

• Buprenorphine is a partial opioid agonist that helps to minimize withdrawal and lessen opioid cravings and use.
• Long-acting injectable buprenorphine (LAIB) is ideal for patients with OUD who have difficulty taking daily medication or do not want to take daily medication.
• LAIB provides extended protection against overdose as it gradually tapers. If a dose is missed, the slow taper reduces the severity of withdrawal symptoms.
• LAIB ensures the patient receives the medication consistently and doses are not skipped.
• This protocol suggests using Brixadi (weekly) to initiate treatment because of a lower risk of withdrawal symptoms; however, any LAI formulation is appropriate and recommended if your setting does not have Brixadi (weekly), or the patient prefers a longer-acting formulation.
• The following is a comparison of the two available formulations:

Supplemental medications

• It may take several days for the injection to achieve clinical effect. Additional medications should be provided to ease withdrawal symptoms.
• Sublingual buprenorphine should be provided to all patients starting LAIB to manage withdrawal symptoms while adjusting to the medication.
• Some patients will also need sublingual buprenorphine to manage cravings as the time for their next injection approaches.
• Provide prescriptions for appropriate adjunct medications for withdrawal symptoms.
• Some patients may need to transition from Brixadi to Sublocade to adequately treat OUD symptoms, as it provides a higher serum level.

• Active 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 or methadone. 

• Administer by subcutaneous injection only. Serious harm or death may result if administered intravenously.  Long-acting injectable buprenorphine forms a solid mass when it comes into contact with body fluids.

• LAI buprenorphine formulations are administered via subcutaneous injection. Never inject intravenously, intramuscularly, or intradermally.
• Pre-administration preparation:
  • If using Sublocade, allow it to reach room temperature. Brixadi does not require refrigeration.
  • Put patient in supine position.

  • Identify an injection site in the subcutaneous tissue of the buttock, thigh, abdomen, or upper arm. 

    

• Inspect the injection site for rashes, open sores, scars, or skin irregularities. If these are present, select a different site.
• Pain management:
  • Patients may experience a burning sensation during injection. This is more commonly reported with Sublocade than Brixadi. Ensuring the patient has a good experience with the injection will help them engage in ongoing care for follow-up injections.
  • Minimize discomfort with one or more of the following strategies:
    • Prep the area with an ice pack directly on skin for 20 minutes
    • Lidocaine (intradermal/subcutaneous or EMLA cream)
    • Mindfulness techniques
• Administration:
  • Administer subcutaneously at 45-90° angle, depending on amount of adipose tissue. Inject slowly.
  • The medication will form a solid mass that slowly absorbs over time. Sublocade creates a palpable mass, whereas Brixadi may not be palpable.
• Document the site of injection. Sites must be rotated to prevent irritation.
• Advocate for all patients to receive additional sublingual buprenorphine and adjunct medications for withdrawal symptoms and administer as prescribed.

• 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.
• Provide the patient with a buprenorphine prescription to last until their scheduled outpatient appointment. When possible, prescribe 3 additional days beyond the appointment date to allow for barriers or rescheduling. If no appointment is scheduled, provide at least 7-14 days of medication to give the patient time to secure an appointment.
  • Patients can call the Washington Telebuprenorphine Hotline (206-289-0287) if they run out of medication prior to their follow up appointment.
• Provide the patient with discharge instructions that include the time of the last dose and when to take the next dose. Ensure the patient understands the importance of taking buprenorphine at around the same time every day.
• Many patients need adjunct medications to control withdrawal symptoms until they stabilize on buprenorphine. If needed, provide prescriptions for adjunct withdrawal management medications to cover at least 7 days.
• 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.
• When possible, connect patients with supports such as social workers, care navigators, or peers to improve patient experience and strengthen linkage to care. 

Educate the patient about:

• Buprenorphine administration:
  • Must be administered under the tongue for proper absorption.
  • It can take 5-10 minutes for the medication to fully absorb. Avoid eating, drinking, smoking, or talking during this time.
  • Drinking water prior to administration can help it dissolve faster.
  • To prevent oral decay, rinse mouth with water 30 minutes after administration.
• The risks of combining sedatives with buprenorphine, which can cause respiratory depression.
• The importance of avoiding driving or operating machinery until accustomed to the medication. Provide work notes if needed.
• Overdose prevention strategies. 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 need to establish follow-up care before the next injection is due.