Quick Guide: Buprenorphine Initiation Algorithm

Adjunctive meds: 

The following can be prescribed PRN for symptoms of withdrawal 

 • Acetaminophen 650 mg PO q 6 hours daily PRN pain 

 • Clonidine 0.1-0.3 mg PO q 6-8 hours PRN w/d symptoms (NTE 1.2 mg/day, hold if BP < 100/70) 

 • Diphenhydramine 25-50 mg, PO q 8 hours PRN insomnia/anxiety 

 • Loperamide 4 mg PO initially, then 2 mg PRN each additional loose stool (NTE 16 mg/24 hours) 

 • Ondansetron 4 mg PO q 6 hours PRN nausea 

 • Trazodone 50 mg PO qhs PRN insomnia 

 • Melatonin 3 mg PO qhs PRN insomnia 



Patients started in the ED:

● If given total dose of <16 mg in ED, continue to follow day 1 algorithm

● If given total dose 16 mg in ED, hold additional doses on day 1, then day 2 start 16 mg qday

● If given total dose > 16 mg in ED, hold additional dosing until return of cravings/withdrawal, then start 16 mg qday

● If patient is experiencing pain may split dose TID



Subsequent days:

● Administer total daily dose from previous day as single dose in am – split TID if ongoing pain

● Increase dose prn cravings/withdrawal/pain

● Decrease dose prn sedation, insomnia, adverse effects

● Typical max dose 24 mg



Support for Hospital Opioid Use Treatment (SHOUT)



#Buprenorphine #Initiation #Algorithm #Treatment #Management #Addiction #Opiate #Start #Prescribing #Inpatient