MOUD Prescriber Guide

Preferentially use Suboxone unless the patient is pregnant, using a microdosing protocol, or an outside OTP/OBOT has clearly maintained the patient on Subutex.

• Even in pregnancy, Suboxone is often the preferred product
• There is theoretical benefit to using the Subutex formulation for induction doses, but the patient should subsequently be transitioned to Suboxone after Day 1 unless there is a clear indication for Subutex
• If prescribing Subutex for OBOT patients without intention to switch to Suboxone, clearly document the reason in the chart (e.g., patient reports swelling with naloxone products). Also discuss early in treatment that: (1) many pharmacies do not stock Subutex, and (2) many insurance plans, including Medicaid, will not cover monoproduct without a PA — the patient may need to pay out-of-pocket until their outpatient provider completes the PA.

JFK ADATC uses a normodosing (as opposed to microdosing or macrodosing) strategy for initiating buprenorphine in the vast majority of cases. Buprenorphine is used in conjunction with an array of supportive medications for withdrawal.

Timing of first BUP dose depends on COWS, time since last opioid use, and type of last opioid used:

• Day 1: 2–4 mg SL initial dose. Give subsequent 2–4 mg doses q2–4h if still in marked withdrawal. Reasonable Day 1 doses at JFK range from 8–16 mg.
• Day 2: Give the total of Day 1's dose in the morning. If still in marked withdrawal in 2–4 hours, give another 4 mg.
• Target maintenance: 16 mg/day. After several days at 16 mg, may consider increasing based on persistent craving. Be mindful that some OBOTs/OTPs will not allow doses >16 mg.

2 mg SL, increase by 2 mg/day if tolerated, up to 16 mg/day.

• Coordinate with pharmacy, Kathleen Parks, and Drs. Patil or Cruz from the very beginning if considering Sublocade
• Patient must be on 8–24 mg BUP SL per day for at least one week before administering
• Typical dosing: 300 mg SQ q1month × 2, then 100–300 mg q month
• May give dose and have patient follow up at OTP/OBOT the next month
• Medicaid: 2–3 days to special order. Other insurance: 2–3 weeks.

• Initial dose: 10–30 mg × 1 if verified heavy opioid use AND in withdrawal
• The maximum allowable initial methadone induction dose under federal law is 30 mg
• Providers with experience may give additional dose(s) of 10 mg q3–4h × 1–2 additional doses if initial dose does not result in adequate resolution of withdrawal symptoms. Patient must be assessed by provider before each additional dose. Do NOT give additional doses if the patient is sedated. Max cumulative Day 1 dose: 40 mg.
  • Note: the 40 mg Day 1 max does not apply to patients receiving methadone prior to admission whose dose has been verified and dosing records obtained for the prior week.

After initial induction, once patient has reached 40 mg, typical titration schedules at JFK:

• 5 mg every 3 days, OR
• 10 mg per week

Start at 5 or 10 mg, increase weekly by 5–10 mg.

• Reduce by 5–10 mg per week max (some recommend 5–10% per week or 2.5 mg/week)

To transition to BUP:

1. Wean down to 30–40 mg methadone and keep dose steady for 1–2 weeks
2. Stop methadone for ≥48–72 hours minimum; patient must be in marked withdrawal before starting BUP
3. Induce BUP: 2 mg, wait 4 hours, then another 4 mg if still in withdrawal but no signs of precipitated withdrawal
4. Warn the patient that they may feel bad for 7–10 days

Keep methadone at full dose × 6 days while adding Subutex. There is theoretical benefit to using the Subutex formulation when microdosing.

The above dosing is a guideline; deviation may be appropriate in individualized cases. If a discharge bridge prescription is needed, prescribe the Suboxone formulation unless there is a definitive indication for Subutex.