Counseling Before Suboxone Initiation: What Providers Should Know

Suboxone is an extremely effective treatment for opioid use disorder (OUD). However, thorough counseling before starting Suboxone is essential. Ensure patients know what to expect, how to report any side effects and how to take the medication properly.

How Does Suboxone Initiation Work?

Suboxone initiation is the process of introducing a powerful opioid agonist into the treatment plan of someone with OUD. It’s a delicate medical procedure that can seem overwhelming or even scary for patients. But with education and your support, people can start using this life-saving medication properly.

Suboxone induction typically involves the following steps:

1. Wait. The patient must experience moderate withdrawal symptoms before using Suboxone for the first time. It’s hard to wait, but doing so can ensure the patient doesn’t experience sudden, powerful withdrawal symptoms when Suboxone starts working. 
2. Start. The patient uses a dose of Suboxone and waits for withdrawal symptoms to fade. If they don’t, the patient takes more and waits again in about two hours. 
3. Repeat. Some patients find the right Suboxone dose on the very first day of treatment. But others need an additional day of taking medications and waiting for a response. 

At the end of the initiation process, the patient has a dose of Suboxone that eases withdrawal symptoms and cravings. That dose is the patient’s therapeutic threshold for the rest of the treatment program. 

Home Initiation vs. In-Office Initiation: Which Is Better?

Historically, many providers insisted that patients start Suboxone while in the office, so they could be monitored and their dose could be adjusted. Studies have shown that beginning Suboxone at home is as effective and safe as office initiation.[1] It allows patients to withdraw in their homes rather than in a less comfortable office setting.[2] 

Most providers feel that the decision to start Suboxone at home or in the office should be shared with the patient. 

The Importance of Counsel About Awaiting Withdrawal Symptoms 

The most important part of Suboxone initiation is ensuring the patient is sufficiently in withdrawal before taking the first dose of Suboxone. If a patient still has opioids in their body when they take their first dose of a partial opioid agonist like Suboxone, the Suboxone binds preferentially to the opioid receptors and “kicks off” the full opioid, causing precipitated withdrawal. 

While precipitated withdrawal is never dangerous or life-threatening, it is extremely uncomfortable. It may make the patient associate the withdrawal symptoms with the Suboxone medication. Therefore, careful counseling about precipitated withdrawal is essential. 

How to Counsel Patients

Counseling about avoiding precipitated withdrawal can be done in two ways: 

1. For patients with clear withdrawal symptoms when they don’t take opioids for some time, counsel them to wait until they feel those withdrawal symptoms come on. Many patients dependent on opioids know exactly what their withdrawals feel like and will therefore be ready to take their first dose of Suboxone. 
   
2. For patients with less severe or obvious withdrawal symptoms, it may be harder to tell when all opioids are out of their body. In these cases, we usually counsel the patient to wait at least 12 hours after taking opioids at a minimum.
   
   This is a good rule of thumb for patients on short- to intermediate-acting opioids ,such as oxycodone, Vicodin or oral morphine. One caveat is that patients transitioning from methadone, which has a much longer half-life, should be advised to wait two days (48 hours) before taking their first dose of Suboxone. 

Withdrawal Symptoms to Look For
If a patient isn’t sure how to tell if they are in withdrawal, they can look for the following symptoms:

• Restlessness 
• Goosebumps
• Heavy yawning
• Stomach cramps
• Body aches
• Nausea or vomiting
• Runny nose
• Enlarged pupils

SOWS

If patients want more guidance to ensure they are in moderate to severe (appropriate) withdrawal before starting Suboxone, you can give them a SOWS (subjective-opioid withdrawal scale):[3]

• They are ready to start if their SOWS withdrawal score is 17 or more.
• If their SOWS withdrawal score is less than 17, they should check their score again in one to three hours and wait until it is 17 or more before starting.

Tell patients: “Wait until you feel very uncomfortable and think you are ready to take your Suboxone. Then, set your alarm for one more hour and take Suboxone after that.”

A helpful article for patients on withdrawal symptoms can be found here.

Help Patients Stay Comfortable Through Early Withdrawal 

We can help our patients get through this withdrawal period by encouraging them to go through withdrawal at night, so they are not uncomfortable throughout the day.

We can also temporarily prescribe comfort medications, or “adjunctive” medications, to help them manage their withdrawal. These are some options to treat specific withdrawal symptoms:

• HTN/anxiety/restless legs: clonidine 0.1 mg po tid
• Diarrhea: loperamide 4 mg po with first loose stool, then 2 mg for each subsequent loose stool; max 24 mg/day
• Pain/myalgias: ibuprofen 600 mg po q 6 hrs or acetaminophen up to 1000 mg po q 8 hrs
• Abdominal cramping: dicyclomine 20 mg po q 4 hrs
• Nausea: ondansetron 4–8 mg po q 8 hrs
• Insomnia: trazodone 50–100 mg po q hrs

A Sample Initiation Protocol

The goal should be a gradual transition from full agonist opioids to buprenorphine while minimizing uncomfortable withdrawal symptoms.

This general initiation protocol is a good option:[4]

• Take a 2 mg film or tablet in the morning at least 12 hours after your last opioid and when you feel like you are in withdrawal. 
• If you tolerate it without worsening withdrawal, take another 2 mg tablet in the afternoon. 
• If you tolerate it without withdrawal, take another 2 mg in the evening.
• If you tolerate it, you can take one additional dose of 2 mg before bed.
• DO NOT go above 8 mg total on the first day.
• The next day, take the total dose you took the day before. For example, if you took 8 mg total the first day, take 8 mg in the morning. 
• Later in the day, if you feel like you are still withdrawing, you can take additional doses. 
• Most patients are on a maximum dose of 8 mg up to three times daily, amounting to no more than 24 mg daily. 

Explain the Process to Your Patients 

Walk them through the initiation protocol. Provide a handout for the patient’s reference, or write out the schedule for them to take home. 

You can also try “teach back,” wherein the patient will explain exactly how to start the medication. If they can state it out loud, they will be more likely to remember it. 

Offer Counseling on How to Take Suboxone

Suboxone most frequently comes as a tablet or strip that needs to be dissolved under the tongue instead of swallowed. It can be tricky for patients to get the hang of at first. 

Remind patients how to take Suboxone properly:

• Prepare for your dose. No drinking, eating or smoking 15 minutes before taking it. If your mouth is dry, sip water before taking the buprenorphine strips or tablets.
• Let it dissolve. Never swallow it, or it won’t work. It must dissolve under the tongue for 15 minutes.
• Don’t interfere. No drinking, eating or smoking for 15 minutes after taking it.

This article about how to take Suboxone under the tongue may be useful.

Check in With the Patient Frequently in the First Few Days 

Research shows that patients are more successful when they have close follow-up care and check-ins from their providers, particularly if they initiate the medication at home.[5]

Let your patient know that you or your nurse will reach out to them, either by phone or in person, 24 to 48 hours after they start the medication. This will put their mind at ease that someone will be available to support them and provide further guidance as needed.

What to Ask During Your Check-In

Use this time to check in about the induction process. Ask these questions:

• How did it go?
• Did they encounter any obstacles? Side effects?
• When did they take their last opioid?
• How long did they wait before taking Suboxone?
• Did they understand the protocol?

Try a New Approach: Microinduction 

For patients with repeated failures at home induction (due to taking their Suboxone too soon or needing a very slow titration of the medication), try microinduction, or microdosing. 

Because it is new, it does not have a large evidence base to support it. However, it is anecdotally a successful new way to start patients who do not tolerate large doses of Suboxone and want to start the medication very slowly to avoid side effects like dizziness or gastrointestinal upset.[5] 

The premise behind microdosing is that the patient continues to take their full agonist opioid while starting with small doses of buprenorphine/naloxone. They then gradually increase their Suboxone amount and come off their full agonist opioid. As a result, they experience minimal withdrawal symptoms during the transition. 

Here is one sample protocol for how to start Suboxone by microdosing. The patient will need to cut the films/tabs provided to take the very small doses of Suboxone.

If you have a patient for whom you think microdosing might be appropriate but aren’t sure how to start, you can refer them to an addiction specialist with more experience with this strategy.

Get Started With Confidence  

The goal of Suboxone initiation is to make the transition from full agonist opioids to Suboxone as easy as possible for patients.

Providing clear expectations from the beginning, giving clear instructions, and ensuring provider outreach can support patients and set them up for a successful entry into long-term recovery.[6]

At Bicycle Health, we have a long list of FAQs about Suboxone and SUD in general for patients that can be found here.