Induction, Stabilization, & Follow-Up
The goal of induction and stabilization is to find the lowest dose of buprenorphine at which the patient discontinues or markedly reduces the use of other opioids without experiencing withdrawal symptoms, significant side effects, or uncontrollable craving for the drug of abuse. The initial induction process requires a higher degree of attention and monitoring than the later maintenance phase. Particular attention should be given to the timing of the initial doses so as to minimize untoward outcomes. Withdrawal symptoms can occur if either too much or too little buprenorphine is administered (i.e., spontaneous withdrawal if too little buprenorphine is given, precipitated withdrawal if buprenorphine is administered while the opioid receptors are substantially occupied by an opioid agonist). Undermedication or overmedication can be avoided through a flexible approach to dosing, which sometimes requires higher doses of treatment medication than expected, and by taking into account patient-reported symptoms.
The stabilization phase is focused on finding the right dose for an individual patient. A patient is stabilized when the dose allows him or her to conduct activities of daily living and to be aware of his or her surroundings without intoxication and without suffering withdrawal or distressing drug craving. Although there is no precise way to determine in advance what the optimal dose for a particular patient will be, most patients are likely to stabilize on eight to 24 mg of buprenorphine per day. More than 24 mg per day likely will not add any benefits and we therefore do not allow prescribing higher doses than 24 mg per day. Buprenorphine blood concentrations stabilize after approximately seven days of consistent dosing, therefore the first prescription will only have enough buprenorphine for a maximum of 7 days, after which a follow-up appointment is necessary. Patients are able to contact our care staff for any issues that may arise in that period, which will either be forwarded to the treating or on call physician.
If withdrawal symptoms subsequently emerge during any 24-hour dosing interval, the dose is too low and should be increased. Medical factors that may cause a patient’s dose requirements to change include (but are not limited to) starting, stopping, or changing the dose of other prescription medications; onset and progression of pregnancy; onset of menopause; progression of liver disease; and significant increase or decrease in weight. Dose adjustments generally can be made in increments of 8 mg/day. Because buprenorphine has a long plasma half-life and an even longer duration of action at the mu opioid receptor, 7 days should be allowed between dose adjustments. Patient adherence to medication regimens and session appointments is associated with better treatment outcomes, and regular monitoring can help patients plan for possible obstacles and teach them ways to handle any problems that occur, therefore once the patient is maintained at a stable dose, the patient needs to be seen on a monthly basis for refills at the least.