Pharmacotherapy

You have options as to what type of MOUD practice you provide. You can limit your practice to buprenorphine maintenance, relying on external referrals for patients. Alternatively, you can start, stabilize, and maintain patients on buprenorphine, and you can determine which patients you will start on MOUD yourself and which patients you will refer elsewhere. Your choices are not static. You can modify your practice as you gain experience or build your practice.

Person-centered care and shared decision-making allows you and the patient options for treatment. You and the patient can determine which medication and which formulation works best for them. In addition, you can choose whether to provide care from your office, remotely at the patient's home, or a combination of both.

View Medication Comparison Chart below.

North Star

The practice has well-designed protocols and systems for all issues related to medication management that are consistent with evidence-based practices and compliant with all legal and regulatory requirements. These protocols incorporate the principles of person-centered care, including shared decision-making.

Prescribing Case Examples: Choosing and Managing MOUD

There is no single approach to prescribing buprenorphine for OUD. However, the following four examples demonstrate common approaches taken in primary care.

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Prescribing Case Examples

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Suboxone Initiation in Primary Care

Patient Information

Name: Maria L.

Age: 45

Substance Use History: Five-year history of heroin use, transitioning to daily smoked fentanyl. Uses multiple times per day to avoid withdrawal. Previously tried a friends Suboxone (buprenorphine/naloxone).

Last Use: ~12 hours prior to the clinic visit.

Withdrawal Symptoms: Nausea, muscle aches, chills, yawning, diarrhea, anxiety, restlessness.

COWS Score: 12 (moderate withdrawal).

Comorbidities: Hypertension (controlled), generalized anxiety disorder; occasional alcohol use but no binge drinking or dependence.

Treatment Goal: “I want to stop using fentanyl completely, stay stable for my kids, and avoid another overdose.”

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Assessment and Planning

Dr. Nguyen conducts a full assessment confirming moderate OUD. Maria reports high motivation following a recent hospital visit after a fentanyl-related breathing issue. Physical exam shows elevated pulse and mild diaphoresis consistent with withdrawal.

Dr. Nguyen explains Suboxone, emphasizing:

Benefits for cravings and withdrawal,
Reduced overdose risk, and
Importance of waiting for sufficient withdrawal, particularly with fentanyl exposure.

Maria expresses understanding and willingness to start induction at home. Dr. Nguyen asks, “When you used your friend’s Suboxone, what dose worked for you?” She says, “24mg/day.” So, Dr. Nguyen prescribes 8mg/2mg buprenorphine/naloxone tablets, 1 tab tid for 7 days, #21 to her pharmacy. Dr. Nguyen also prescribes Naloxone.

Follow-up visits are scheduled for the next two weeks, along with an optional behavioral health referral.

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Induction

Confirm COWS ≥ 12.
Initial dose: 4 mg Suboxone SL, observed in clinic.
Reassessed at 45 minutes: withdrawal reduced but not fully controlled → administered additional 4 mg.
Final dose for day one: 8 mg total, with instructions for evening dosing only if withdrawal reappears.
Provided written instructions, overdose prevention counseling, and naloxone for home use.

Maria leaves the clinic reporting, “I feel normal for the first time in years.”

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Stabilization

During the next week, Maria’s cravings drop significantly. She reports occasional evening restlessness. She begins incorporating mild exercise and anxiety-management strategies. Urine drug screens show buprenorphine but no other opioids; she reports improved sleep and more engagement with her children.

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Maintenance

Maria maintains stability on 24mg Suboxone daily, attending monthly visits. Her functional improvements include steady employment and reduced anxiety. She understands she may stay on Suboxone long-term and expresses no desire to taper at this stage.

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Telehealth-Based Home Buprenorphine Induction

Patient Information

Name: Hannah W.

Age: 41

Substance Use History: Four-year history of escalating opioid use beginning with nonmedical oxycodone, transitioning to daily fentanyl. No previous formal treatment; one prior attempt to quit by self-tapering led to severe withdrawal.

Last Use: ~10 hours before the scheduled telehealth visit.

Withdrawal Symptoms: Restlessness, chills, runny nose, anxiety, stomach cramps, difficulty focusing.

COWS Score (patient-guided via telehealth): Estimated 10–11 (moderate withdrawal) using visual and verbal assessment.

Comorbidities: Controlled hypothyroidism; mild depression; single mother with limited transportation.

Treatment Goal: “I want something stable I can do from home so I don’t keep getting sick or risking overdose.”

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Assessment and Planning (Telehealth)

Hannah schedules a telehealth visit due to limited childcare and transportation barriers. During the video evaluation, Dr. Reynolds diagnoses severe opioid use disorder.

Dr. Reynolds explains that buprenorphine can be safely initiated at home with proper support and monitoring, emphasizing its role in reducing cravings, withdrawal, and overdose risk. A risk management approach is reinforced: safer use practices, naloxone availability, and minimizing risk until medication is active. Hannah is motivated to stop fentanyl and start buprenorphine. However, when Dr. Reynolds asks her if she has ever used buprenorphine before, she says, “No.” She has stable housing, internet access, a phone, and a housemate who can check on her. Her local pharmacy is confirmed.

Together they plan a home induction, with scheduled telehealth check-ins:

Dr. Reynolds prescribes 8mg/2mg buprenorphine/naloxone tablets: 1 sublingual tab bid for 3 days, #6. He explains that she needs to be in mild to moderate withdrawal before placing the buprenorphine tab under the tongue. If taken too close to the last fentanyl use, she could experience precipitated withdrawal.
For maximum absorption of the buprenorphine: “Don’t eat, smoke, vape, or drink caffeinated beverages for 10 minutes beforehand. The mouth needs to be damp. If not, put a small amount of water in your mouth. Then place the tablet under the tongue for 10 minutes. Do not swallow your spit during this time. After 10 minutes you will not absorb any more of the medication, so you can spit out the warm spit wad.”
A follow-up telehealth visit is set up in 3 days.
Naloxone is dispensed.

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Induction (Home-Based)

Hannah follows the home induction plan.

Three days later, Dr. Reynolds and Hannah have a telehealth appointment. She reports continued mild withdrawal and cravings, but notes she is using “a lot less fentanyl.”

Dr. Reynolds increases her buprenorphine/naloxone to 24 mg/day, 1 sublingual tablet tid for 3 more days. He again reviews how to take the medication and schedules a follow-up visit.

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Stabilization

At the next-day telehealth follow-up:

Hannah reports waking without withdrawal,
No fentanyl use, and
Improved clarity and mood.

Based on her symptom report, Dr. Reynolds maintains her on 24 mg daily, explaining this is a common therapeutic level.

Over the next two weeks via telehealth, Hannah reports:

Cravings decrease significantly,
Stable functioning while caring for her children, and
Mild nausea resolves with hydration and slower administration.

She begins optional virtual counseling sessions offered through a clinic with whom Dr. Reynolds has a relationship.

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Maintenance

After one month:

Hannah remains stable on 24 mg/day buprenorphine.
She has no return to nonmedical opioid use.
She attends telehealth follow-ups every 2–4 weeks.
Transportation and childcare barriers are no longer obstacles to treatment.
She continues weekly virtual counseling sessions.
She expresses interest in eventually joining a virtual support group.

Hannah says, “Being able to start this from home made treatment finally possible for me. If I had to wait for rides or childcare, I might not have gotten help at all.”

Dr. Reynolds continues long-term maintenance planning, emphasizing a chronic disease model and the value of ongoing medication.

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Transition to Injectable Buprenorphine After Sublingual Buprenorphine Challenges

Patient Information

Name: James T.

Age: 29

Substance Use History: Daily intranasal fentanyl for ~3 years; several periods of unstable housing; multiple unsuccessful outpatient inductions due to missed doses and difficulty adhering to daily medication.

Last Use: This morning (5 hours ago).

Withdrawal Symptoms: Rhinorrhea, sweating, abdominal cramping, anxiety, dilated pupils.

COWS Score: 10 (mild–moderate).

Comorbidities: Mild asthma; cannabis use; episodic depression without current suicidal ideation.

Treatment Goal: “I want something long-lasting so I don’t have to worry about taking a dose every day.”

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Assessment and Planning

James previously attempted sublingual buprenorphine three times but had:

Difficulty achieving adequate withdrawal and experienced precipitated withdrawal once.
Lost medication twice due to unstable housing.
Adherence issues leading to continued fentanyl use.

Dr. Patel reviews these challenges and explains that extended-release injectable buprenorphine (e.g., monthly buprenorphine XR) could provide:

Consistent blood levels,
Improved adherence,
Reduced craving and risk of use, and
No daily medication burden.

Because James is not fully withdrawn, Dr. Patel plans a brief in-clinic sublingual (SL) induction to ensure tolerability prior to injection.

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Induction

Initial SL dose: 2 mg buprenorphine/naloxone SL, monitored for 45 minutes.
James experiences improvement in withdrawal without precipitated symptoms.
Additional 6 mg given to achieve stabilization before the injection.
After confirming tolerability and adequate symptom control, Dr. Patel schedules same-day initiation of the extended-release injection.
Dr. Patel prescribes Naloxone as well. James says he knows how to use it.

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Stabilization (Injectable Transition)

James receives the first monthly buprenorphine XR injection in the abdominal subcutaneous tissue.
Observed for 15 minutes with no adverse events.
Reports reduced cravings later in the day and expresses relief at not needing to manage daily tablets.
Follow-up scheduled at 1 week (phone check-in) and 4 weeks (next injection).

Over the next month, James remains adherent and reports significantly less fentanyl use, improved stability, and better control of cravings.

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Maintenance

James continues monthly buprenorphine XR injections with good response.
Engagement in housing support services improves stability.
No missed appointments over three months.
He reports, “Having a monthly shot keeps me stable—this is the first time treatment has actually worked.”

Dr. Patel plans continued monthly dosing. He tells James, “You can be on this medication for as long as it benefits you… which may be indefinitely.”

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Emergency Department (ED) Handoff After Overdose and Buprenorphine Initiation

Patient Information

Name: Trevor M.

Age: 32

Substance Use History: Six-year history of OUD beginning with prescription opioids after a work-related injury, progressing to daily IV fentanyl/heroin use. Multiple prior nonfatal overdoses, no consistent treatment engagement.

Last Use: Immediately prior to overdose; fentanyl injected ~2 hours before ED arrival.

Withdrawal Symptoms (Post-Naloxone): Agitation, sweating, body aches, stomach cramping, nausea.

COWS Score (in ED): 25 (moderately severe withdrawal after naloxone reversal).

Comorbidities: Untreated Hepatitis C; tobacco use disorder; mild anxiety; no benzodiazepine or alcohol dependence.

Treatment Goal: “I don’t want to end up dead. I want treatment this time.”

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Assessment and Planning (ED)

Trevor is brought to the ED by emergency medical services after a bystander-administered naloxone reversal for a suspected fentanyl overdose. He is awake but distressed, displaying moderately severe withdrawal and expressing fear about returning to use once discharged.

The ED team screens for OUD using DSM-5 criteria and confirms severe OUD. After clinical stabilization, they discuss ED-initiated buprenorphine as an evidence-based intervention shown to reduce mortality and increase treatment engagement. Trevor agrees, saying this is the first time he feels ready to start medication.

There are no acute comorbid medical issues requiring admission, and vital signs are stable except for mild tachycardia.

A warm handoff is arranged with Dr. Patel, a primary care physician (PCP) who offers MOUD services in the community. An appointment is secured for the following morning, and the ED team sends documentation, including the induction dose and a treatment summary, to the PCP.

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Induction (ED)

Because Trevor is in moderately severe withdrawal after naloxone reversal, the ED team initiates buprenorphine treatment:

Initial dose: 8 mg buprenorphine/naloxone SL,
Reassessment after 45 minutes: withdrawal reduced but not fully controlled,
Additional dose: 8 mg buprenorphine/naloxone SL, and
Total ED dose: 16 mg.

Trevor reports significant relief of symptoms and expresses gratitude, saying, “This is the first time I haven’t felt sick after an overdose.”

He receives:

A 24-hour bridge prescription for buprenorphine/naloxone to cover until PCP follow-up,
Naloxone kit and education,
Written instructions on what to expect and how to take his second dose if needed overnight,
Contact information for the primary care clinic, and
Reassurance that treatment is continued, not restarted, when he sees his PCP.

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Stabilization (Primary Care)

Trevor arrives at Dr. Patel’s office the next morning. He reports mild residual symptoms but overall improved condition. He took an additional 8 mg dose overnight per ED instructions.

Dr. Patel:

Reviews the ED note and confirms the diagnosis of OUD,
Assesses withdrawal (COWS 6 – mild),
Titrates dose to 24 mg/day buprenorphine/naloxone,
Schedules visits weekly for the first month,
Performs Hepatitis C evaluation and begins planning for treatment, and
Initiates a behavioral health referral but emphasizes it is optional, not required for receiving medication.

Trevor begins to stabilize over the next two weeks with reducing cravings, improved sleep, and decreased fentanyl use (eventually none).

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Maintenance

After one month, Trevor remains stable on 24 mg/day. He has not returned to fentanyl use and is attending primary care visits biweekly, soon transitioning to monthly appointments.

Long-term treatment goals include:

Completing Hepatitis C treatment,
Improving physical conditioning,
Rebuilding relationships with family, and
Returning to steady employment.

Trevor states during a maintenance visit, “Starting buprenorphine in the ER probably saved my life. If they hadn’t done that, I don’t think I’d have made it to your office.”

The PCP team continues maintenance therapy using a chronic disease management model, emphasizing reducing risks, preventing return to use, and long-term stability.

Medication Comparison Chart

Name	Action Mechanism	Forms	Uses	Typical Maintenance Dosage ^a	Restrictions
Methadone (e.g., Methadose)	Agonist	Liquid Oral tablet	Withdrawal & treatment	Daily Tablet or liquid (60-120mg)	Dispensed in opioid treatment programs
Buprenorphine (e.g., Subutex, Sublocade, Brixadi, generic)	Partial agonist	Sublingual tablet, Sublingual film, Subcutaneous long-acting injectable	Withdrawal & treatment	Daily tablet or film (<6-24mg)^a Injection: Weekly (8-32mg) Monthly (64-128mg)	DEA licensed provider
Buprenorphine/naloxone (e.g., Suboxone, Zubsolv, generic)	Combination	Sublingual tablet Sublingual film	Withdrawal & treatment	Daily Sublingual tab. (16/4mg) > (buprenorphine/naloxone)	DEA licensed provider
Naltrexone (e.g., ReVia, Vivitrol,vDepade)	Antagonist	Injectionv (IM)	Treatment	Monthly injection (380mg)	None
^a FDA changed package insert wording in late 2024 to make clear that, "daily maintenance dosages can be incrementally adjusted for each patient based upon their individual therapeutic need and that daily doses higher than 24 mg per day may be appropriate for some patients."¹ Recent discussion is that the dosing can and should go higher for those using fentanyl.¹ Doses as high as 32 to 40 mg have been suggested,²and higher doses have been associated with both better MOUD treatment retention³ and lower urgent care utilization.⁴

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1. Center for Drug Evaluation and Research. FDA recommends changes to labeling for transmucosal buprenorphine products indicated to treat opioid use disorder. FDA. Published online December 26, 2024. Accessed June 4, 2025. https://www.fda.gov/drugs/drug-safety-and-availability/fda-recommends-changes-labeling-transmucosal-buprenorphine-products-indicated-treat-opioid-use

2. Grande LA, Cundiff D, Greenwald MK, Murray M, Wright TE, Martin SA. Evidence on Buprenorphine Dose Limits: A Review. J Addict Med. 2023;17(5). doi:10.1097/ADM.0000000000001189

3. Harris R, Stracker N, Rice M, St. Clair A, Page K, Rosecrans A. Redefining low-threshold buprenorphine access in an integrated mobile clinic program: Factors associated with treatment retention. J Subst Use Addict Treat. 2025;169:209586. doi:10.1016/j.josat.2024.209586

4. Axeen S, Pacula RL, Merlin JS, Gordon AJ, Stein BD. Association of Daily Doses of Buprenorphine With Urgent Health Care Utilization. JAMA Netw Open. 2024;7(9):e2435478. doi:10.1001/jamanetworkopen.2024.35478

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The first phase of MOUD treatment is when buprenorphine or one of the other MOUD medications is first administered. This is the most nuanced phase of treatment, and establishing a relationship with an experienced mentor can help you navigate it. If there is fentanyl involvement, review the guidance on dosing (PDF - 1.0 MB) in the Quick Start Guide or you may choose to have a specialty SUD clinic or an OTP begin the patient's medication for OUD. Before you begin treatment, there are key decisions to make in collaboration with the patient, and several considerations to keep in mind.

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Choice of Medication

Every patient is different and will have their own needs and preferences related to medication. When choosing medication (i.e., buprenorphine monoproduct or buprenorphine/naloxone combination) and form (i.e., tablet, film, or LAI), balance the risks and benefits of the medication, along with lifestyle factors that can affect treatment adherence. Also consider referral to an OTP where methadone can be provided, or to a higher level of care, depending on the complexity of the patient's presentation. Keep in mind that some payers limit what medications and treatments are reimbursable, and treatment availability plays a role.

"Currently no empirical data indicate which patients will respond better to which opioid use disorder medications."¹

Consider the following when deciding which treatment to provide:¹

Patient preference, including their prior history with and response to medications for OUD;
Type of misused opioid (e.g., fentanyl, prescription opioids, heroin), the extent of physical dependence on the opioid, and use of other substances, whether intentionally or not;
Side effects associated with medications;
Patient characteristics and lifestyle (e.g., employment, scheduling limitations, pregnancy status, age, etc.); and
Coverage, as payers may limit which forms of medication they cover.

Buprenorphine is a partial opioid agonist that does not fully activate the mu opioid receptors, resulting in less euphoria and fewer breathing problems than full agonists like methadone. However, buprenorphine still carries some small risk of misuse or lethal overdose when combined with other sedating substances.

There is also a significant risk of diversion with the oral formulations of buprenorphine. To reduce the risk of misuse or diversion, providers often prescribe a medication that combines buprenorphine with naloxone, an antagonist that blocks mu opioid receptors when injected intravenously. When these buprenorphine-naloxone combination products are taken properly--either as a sublingual tablet or as a film placed sublingually (under the tongue)—the naloxone is minimally active. However, if someone tries to inject or snort the medication, the naloxone becomes more bioavailable, reducing the effects of the buprenorphine. However, some scholars have argued that the addition of naloxone may only delay the onset of euphoric symptoms.² In addition, some clinicians have expressed concern that the negative side-effects of naloxone in the combined product are underestimated.

Buprenorphine treatment for OUD expands treatment access by enabling any medical provider with a DEA license to treat individuals with OUD in their practice. Different modes of administration provide flexibility to tailor treatment to the individual patient's needs. For example, long-acting buprenorphine injections can be administered weekly or monthly, which can improve adherence. These injections can be ideal and convenient for many patients, including those who are incarcerated or transitioning out of incarceration.

Long-acting injectable buprenorphine is a newer option, suitable for patients with moderate to severe OUD who struggle adhering to a daily buprenorphine schedule or prefer less-frequent dosing due to their personal circumstances and preferences. It is important to note that patients do not typically begin MOUD with injectable buprenorphine; patients are first stabilized on transmucosal buprenorphine before transitioning to the injectable form.⁴ Table 2 in the Playbook's Quick Start Guide summarizes the different types of medications for OUD available, including the forms and typical dose ranges. Sources for more information can be found in the Resources.

Know which pharmacies in your community will reliably fill your MOUD prescriptions. Patients typically need to visit local pharmacies to obtain the MOUD you prescribe, so it is worthwhile to know which pharmacies stock the medications. Some formulations are more challenging to procure, such as long-acting injectable (LAI) buprenorphine which is subject to Risk Evaluation and Mitigation Strategy (REMS) regulations.^5,6

Some pharmacies are reluctant to stock buprenorphine medications for fear of being identified in the Suspicious Opioid Reporting System^7,8 that was established to limit diversion of the medication. To address this national problem, the National Association of Boards of Pharmacy and the National Community Pharmacists Association have collaborated to develop The Pharmacy Access to Resources and Medication for Opioid Use Disorder (PhARM-OUD) Guideline (PDF - 606 KB). Also, online pharmacies are now available to fill in the gap when local options are limited.

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Approaches to Starting Buprenorphine

As with the type of medication you select for a given patient, you have choices about how you start the patient on the medication. You can start MOUD in your primary care setting or rely on specialty clinics or OTPs to do so, after which the patient may be a good candidate for maintenance treatment in primary care, as described in Phase III.

Starting MOUD in patients who use fentanyl can be nuanced. Most of the existing literature on starting buprenorphine is based on people using heroin or prescription opioids. Starting buprenorphine following fentanyl misuse can involve a greater risk on patients entering precipitated withdrawal (see Managing Withdrawal Symptoms), which can make them more reluctant to continue treatment. Fentanyl purchased on the street is often illicitly manufactured and is unpredictable in both dosage and composition, frequently mixed with substances such as xylazine or stimulants.⁹

As described in Figure 2, one model for primary care providers is to specialize in buprenorphine maintenance and encourage and accept referrals from other settings (e.g., emergency departments, in-patient settings, jail/prison) after patients have started the medication.

There is no single agreed-upon protocol for starting MOUD. The most common approach is to begin buprenorphine when the patient is experiencing mild to moderate withdrawal symptoms. You can assess a patient's withdrawal symptoms throughout the process using the Clinical Opiate Withdrawal Scale (COWS) (PDF - 606 KB) in your office or the Subjective Opiate Withdrawal Scale (SOWS) (PDF - 225 KB) if the patient is at home. Buprenorphine initiation can last anywhere from several days to a week or more.¹⁰ Look at the Quick Start Guide for the most recent (2025) guidance from the American Academy of Family Physicians on starting buprenorphine in primary care settings.

Starting MOUD in the office or starting at home: MOUD can be started in an observed, office-based setting or at home by the patient. Most clinical trials of buprenorphine included office-based initiation, which led to longstanding recommendations that it must be started in a medical setting to be safe and effective. However, more recent evidence indicates patients can successful start the medication in either setting.¹¹ Many experts support starting the medication at home, in combination with telehealth,¹² which has been associated with improved retention early in buprenorphine treatment.

Office-based inductions: Office-based initiation of MOUD can be difficult to schedule and may require a significant amount of provider and staff time, which can create delays and barriers to treatment initiation. In-office initiation can be reserved for more complex cases, such as patients transitioning from methadone or other long-acting opioids to buprenorphine, or those who have previously had problems starting buprenorphine.
Home inductions: It can be advantageous to begin MOUD at home, particularly in uncomplicated cases, as it can be safe and appropriate for many patients.^13,14,25 There are no single agreed-upon protocols for starting buprenorphine but typically, you would schedule a visit (in-person or via telehealth) to discuss the protocol with the patient beforehand. Be sure to support patients throughout the process, by providing adequate education on what they should expect and by communicating via phone or text message.
The protocol might include instructions for timing the medication start (i.e., the appropriate level of withdrawal), dosing (what dose to take at what interval or based on what factors, maximum dose, etc.), how to monitor to process (schedule telehealth check-in times during the start, determine after-hours availability if the patient has questions, etc.), and schedule your next visit (in-person or via telehealth).
Be sure to support patients throughout the process, by providing adequate education on what patients should expect, communicating via phone or text message as needed during the process, and having follow-up visits soon afterward.
Note that individuals who use fentanyl may be more likely to experience precipitated withdrawal (the rapid onset of withdrawal symptoms) when starting buprenorphine, which can complicate starting at home.

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Managing Withdrawal Symptoms

Many people with OUD fear the symptoms of withdrawal and even cite this as a reason for continued use, as exemplified in the following quotes:¹⁵

"Once I had an everyday habit, I was no longer using for the calming effects. I was using to avoid a painful physical withdrawal… I had to get high every day just to feel normal."¹⁶

"The physical withdrawal was fiercely uncomfortable… It would start a nervous tick, such as excessive yawning or sneezing. Symptoms would progress to body aches and stomach pain… After several hours of not using, the constipating effects of heroin would wear off, causing uncontrollable diarrhea. Hot and cold sweats, restless legs, vomiting, lack of appetite and severe body pains caused insomnia that made the withdrawal even more miserable."¹⁶

Symptoms: The symptoms of opioid withdrawal vary across individuals and are influenced by factors such as the type of opioid used and duration of use. Initially, withdrawal symptoms resemble those of the flu. According to DSM-5 (p. 547),¹⁷ withdrawal symptoms include the following:

"Dysphoric mood;
Nausea or vomiting;
Muscle aches;
Lacrimation or rhinorrhea;
Pupillary dilation, piloerection, or sweating;
Diarrhea;
Yawning;
Fever; an
Insomnia.

Withdrawal symptoms can begin immediately (in response to administration of an antagonist) or emerge gradually over the course of several hours to days. The temporal onset, duration and severity of symptoms vary based on multiple factors, including the type and amount of non-prescribed opioid used, the extent of physical dependence, and individual patient characteristics. Clinical Opiate Withdrawal Scale (COWS) (PDF - 606 KB) can be used to assess the severity of withdrawal symptoms.

Symptom Relief: Several medications can be used in to ease the discomfort of withdrawal symptoms while starting MOUD, such as:

Alpha 2 agonists (e.g., clonidine) for anxiety, agitation, and muscle aches;
Non-opioid analgesics (e.g., ibuprofen, acetaminophen) for minor aches and discomfort;
Antispasmodics (e.g., dicyclomine) to treat abdominal cramps;;
Anxiolytics (e.g., hydroxyzine, gabapentin) for nervousness, agitation, and nausea;
Hypnotics (e.g., trazodone) for anxiety, insomnia, and agitation;
Antiemetics (e.g., ondansetron) for nausea; and
Anti-diarrheal (e.g., loperamide) for diarrhea.^14,18

Keeping patients as comfortable as possible while starting MOUD will decrease the likelihood of premature treatment attrition.¹⁸

The goal of stabilization is to determine the dose of medication needed to minimize side effects while eliminating cravings and withdrawal symptoms. Patients in this phase have stopped or significantly decreased their non-prescribed opioid use, although some patients may continue to use other substances.

Finding the Right Dose: Once a patient is on buprenorphine, ongoing cravings, opioid withdrawal, or ongoing opioid use are all indicators to consider increasing the dose. Dose ranges from 16-40mg of buprenorphine daily may be needed to suppress these symptoms, and evidence is mounting that higher doses are linked with greater retention of MOUD²⁶ and lower urgent care utilization.²⁷ Reviewing the correct way to take the sublingual medication may be needed to properly achieve the full dose. Swallowing too much of the secretions too soon can result in a lower dose.¹⁹

Frequency of Visits: See patients frequently, either in-person or via telehealth, during the first few weeks of treatment as they stabilize on the medication. Initially, you may see them weekly or more often if needed. Once you and the patient agree they are comfortable and stable on the medication and dose, you can decrease the frequency of visits. Review your state's Medicaid guidelines or those of the patient's insurer as they may contain specific requirements for visit and urine drug screen frequency.

Patient Comfort: Try to address and manage any side effects during patient visits. Side effects may be related to the medication itself or to withdrawal, which may mean the dose needs to be adjusted. Symptoms may include constipation, taste perversion, headache, nausea, vomiting, sweating, joint and muscle pain, sedation, anxiety, symptoms of allergic reactions, insomnia, and decreased libido.

Psychosocial Supports: During stabilization, ongoing efforts to promote engagement and retention in treatment can be critical. As patients' withdrawal symptoms decrease, this may be a good time to further assess their needs and connect them with additional supports. For example, psychosocial supports may help address any co-occurring mental health conditions that may affect a patient's ability to stabilize on the medication.²⁰ See Counseling and Other Psychosocial Supports.

If patients are ambivalent about decreasing opioid use or making other changes, motivational interviewing techniques can help them explore and understand their hesitation. Learn more in the section on Person-Centered Care Plans.

Individuals in the maintenance phase should be progressing well on a steady dose of buprenorphine. Their withdrawal symptoms have resolved. During maintenance, the patient is feeling better physically and will be adjusting to the 'new normal' without using the non-prescribed opioid and without fearing withdrawal symptoms.

Focus on Providing Buprenorphine Maintenance. Some primary care providers may choose to focus on providing buprenorphine maintenance (medication management) for patients already in the maintenance phase. In this model, starting buprenorphine, which is the most complex part of providing this medication, is done in other care settings. This model can also be used for patients who have successfully been in buprenorphine maintenance for a while and no longer require the same level of care.

This approach could be a straightforward way to start prescribing medications for OUD. It could be the only type of buprenorphine treatment you provide. Alternatively, this approach could be used while you establish the supports and connections for more whole-person treatment of people with OUD.

This approach may necessitate a referral stream and collaboration with other organizations. You may already have some patients in your practice who are receiving their MOUD prescription elsewhere. Taking over their prescription is an option. New referrals can come from emergency departments, in-patient medical or psychiatric facilities, prison/jail/law enforcement, OTPs/specialty SUD clinics, social services, pain clinics or specialists, and so forth.

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Medication Management Visits

Use medication management visits to monitor your patient's progress, functional status, and the appropriateness of their treatment plan. These visits are also an opportunity to assess the risk of recurrence of use and to administer any screenings or assessments not conducted earlier. This is also a good time to link patients with resources and supports. Use these visits to assess:

Medication adherence;
Cravings and withdrawal symptoms;
Substance use;
Life and social stressors;
Any other relevant medical issues;
Mental health issues, suicidal thoughts — consider providing psychiatric medications, if appropriate, and/or referral to a mental health provider;
Social support, engagement with recovery supports or counseling; and
Results of laboratory tests.

If medication management visits indicate a patient is at risk of or has resumed using non-prescribed opioids, take appropriate steps. Learn more in Prevention and Response to Recurrence of Use.

Frequency of Visits: The following signs may indicate a patient is ready to decrease visit frequency:²⁵

Several weeks of no opioid use;
Continued attendance at scheduled appointments and adherence to the treatment plan; and
Engagement in treatment to address co-occurring mental health or medical concerns.

Patients who are ready to decrease the frequency and intensity of treatment visits will also show no evidence of the following:

Co-occurring substance use that may pose significant risk to their safety;
Significant side effects from medication; or
Signs of diversion (e.g., early refill requests, unexpected prescriptions from other providers in the prescription drug monitoring program, no buprenorphine in the urine drug screen).

Brief Supportive Counseling: If your practice has begun to integrate behavioral health and primary care so that you have behavioral health professionals on site or in a collaborative relationship, additional counseling or therapy may be possible in-house. Medication management visits also offer an opportunity for you or other members of the care team to provide brief supportive counseling, as you would with any other chronic disease. You can use the following strategies for brief counseling:²⁵

Identify triggers and manage stressors;
Listen empathically and have discussions with patients in a nonjudgmental manner;
Assess progress against treatment goals and revise these goals as needed using shared decision-making techniques (See Resources);
- Provide medical care for co-occurring physical health conditions;
- Identify patient needs and refer to other providers as needed (including mental health treatment, substance use counseling, case management, and community-based recovery support);
- Have patients invite family and friends to medication management visits to discuss how they can support the patients and to educate those who are reluctant to accept the use of medication to treat OUD. This may also be an opportunity to engage the support persons if they display evidence of OUD; and
- Advocate for patients if their retention in treatment is challenged by their employer, housing provider, insurance company, or the criminal justice system.

Patients may be surprised by the level of emotions they experience once non-prescribed opioids and other substances are out of their systems. It is not uncommon for unresolved trauma, guilt, and shame to surface once active addiction subsides. This can be a valuable time for the patient to seek counseling and other supports, if they have not already.

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Treatment Duration

The maintenance phase has no standard length, but it is generally the case that the longer the treatment duration, the lower the likelihood of all-cause mortality.^21,22 Some experts have concluded that 1 year should be the minimum, and the research evidence suggests that even longer treatment periods are associated with reduced risk of overdose deaths.²³

"Providers should encourage patients to stay on MOUD for as long as it is beneficial for the patient." — Subject Matter Expert

"…maintaining patients on OUD medication for years, decades, or even a lifetime if patients are benefitting." — SAMHSA TIP 63 expert panel²⁵

Discontinuation of Buprenorphine Treatment: When patients have met their treatment goals and have stability in their lives, they may want to taper off buprenorphine completely.²⁴ This decision is one that should be taken with great care, given the much higher risk of overdose and death following termination of MOUD. If a patient continues to be interested in discontinuing MOUD after they've been made aware of the increased risk, use shared decision-making to discuss this plan with the patient (See more in the Resources section).

If your patient ultimately decides to stop using their medication, slowly taper the dose and monitor them closely. Do not rush to discontinue medications for OUD. It is risky, and patients who stay on buprenorphine or methadone tend to have better outcomes than those who undergo medically supervised withdrawal. If you are considering discontinuation, make sure you have a plan to prevent recurrence of use and planned response if it happens. Make sure patients and their families understand that discontinuing medications can increase a patient's risk of returning to using non-prescribed opioids, overdose (particularly as their tolerance may be much lower than they expect), and death.²⁵

Don't underestimate the therapeutic benefit of shared decision-making.
Don't unilaterally decide which medication to prescribe for the patient. Allow the patient to have input into this decision through a shared decision-making process between patient and provider.
Don't terminate treatment based on continued substance use; instead consider the appropriateness of more intensive treatment. Similarly, don't set an arbitrary limit on patients' length of time in treatment.
Don't forget to meet patients where they are. Some patients may resist MOUD treatment but want counseling or "detox". This can be an opportunity to engage them and gently use motivational interviewing to promote MOUD for when they are ready.
Don't be discouraged if treatment does not progress as expected. Multiple stops and starts in treatment are common.

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Resources

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Opioid Treatment Program Directory

Provides a directory for opioid treatment programs by State.

Format

Other

Audience

States

Patients

Families

Source

Substance Abuse and Mental Health Services Administration

Year

2019

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A practical guide for buprenorphine initiation in the primary care setting

Detailed description of how to start buprenorphine, including a description of a low-dose induction or overlapping start.

Format

Guide

Audience

Behavioral Health Providers

Medical Providers

Other Team Members

Source

Cleveland Clinic

Year

2023

Resource Type

Web Page

Massachusetts Nurse Care Manager Model of Office Based Addiction Treatment: Clinical Guidelines (PDF - 4.4 MB)

Detailed, extensive instructions for office-based treatment with buprenorphine and naltrexone, including transfer from methadone and injectable buprenorphine; also includes a pre-treatment (pre-induction) checklist and consent forms for treatment and release of information.

Format

Instrument/Protocol

Audience

Other Team Members

Source

Boston Medical Center

Year

2022

Resource Type

PDF

Medications for Opioid Use Disorder Treatment Protocol TIP 63 (updated 2021) (PDF - 3.3 MB)

A comprehensive description of medications to treat OUD. This guidance document includes drug formulations and pharmacology, as well as considerations for dosing, potential drug interactions, risks and side effects, patient selection, treatment initiation, and duration of treatment. This information can help providers and patients make decisions about which medications to prescribe.

Format

Report/Paper/Issue Brief

Audience

Medical Providers

Behavioral Health Providers

Other Team Members

Source

Substance Abuse and Mental Health Services Administration (SAMHSA)

Year

2021

Resource Type

PDF

Medications for Opioid Use Disorder – Michigan OPEN

Clearly presented information for using medications to treat patients with OUD.

Format

Web Page

Audience

Behavioral Health Providers

Medical Providers

Source

The Regents of the University of Michigan

Resource Type

Web Page

Medications for Opioid Use Disorder (MOUD) Primary Care Practice Toolkit

This toolkit provides comprehensive guidance on implementing clinical guidelines and billing
practices to effectively integrate MOUD into clinical environments.

Link

https://groupmosaic.com/wp-content/uploads/2025/01/Mosaic-Group-MOUD-Toolkit-for-Primary-Care.pdf

Format

Guide

Audience

Behavioral Health Providers

Medical Providers

Other Team Members

Source

Mosaic Group

Year

2025

Resource Type

PDF

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The SHARE Approach

A five-step process for shared decision making that uses dialogue to compare the benefits, harms, and risks of each option to help explore what matters most to the patient.

Format

Curriculum

Audience

Medical Providers

Other Team Members

Source

Agency for Healthcare Research and Quality

Resource Type

Web Page

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1. TIP 63: Medications for Opioid Use Disorder | SAMHSA Publications and Digital Products. Accessed February 26, 2025. https://library.samhsa.gov/product/tip-63-medications-opioid-use-disorder/pep21-02-01-002

2. Blazes CK, Morrow JD. Reconsidering the Usefulness of Adding Naloxone to Buprenorphine. Front Psychiatry. 2020;11. doi:10.3389/fpsyt.2020.549272

3. Gregg J, Hartley J, Lawrence D, Risser A, Blazes C. The Naloxone Component of Buprenorphine/Naloxone: Discouraging Misuse, but at What Cost? Journal of Addiction Medicine. 2023;17(1):7. doi:10.1097/ADM.0000000000001030

4. Wason K, Potter A, Alves J, et al. Addiction Nursing Competencies: A Comprehensive Toolkit for the Addictions Nurse. J Nurs Adm. 2021;51(9):424-429. doi:10.1097/NNA.0000000000001041

5. Sublocade REMS. What is the SUBLOCADE® REMS (Risk Evaluation and Mitigation Strategy)? Accessed June 2, 2025. https://www.sublocaderems.com/#Main

6. BRIXADI REMS. Welcome to the BRIXADI REMS (Risk Evaluation and Mitigation Strategy). Accessed June 2, 2025. https://brixadirems.com/

7. Winstanley EL, Gray A, Thornton D. Addressing the Escalating Problems That Patients Encounter When Filling Buprenorphine Prescriptions. JAMA Psychiatry. 2024;81(12):1167-1168. doi:10.1001/jamapsychiatry.2024.3076

8. Kazerouni NJ, Irwin AN, Levander XA, et al. Pharmacy-related buprenorphine access barriers: An audit of pharmacies in counties with a high opioid overdose burden. Drug and Alcohol Dependence. 2021;224:108729. doi:10.1016/j.drugalcdep.2021.108729

9. Syvertsen J, Cabral A, Knaap E, Rey S, Pollini RA. The emergence of fentanyl in a stimulant landscape: Un/intentional use, social relations, and developing communities of care. International Journal of Drug Policy. 2025;140:104807. doi:10.1016/j.drugpo.2025.104807

10. Wesson DR, Ling W. The Clinical Opiate Withdrawal Scale (COWS). J Psychoactive Drugs. 2003;35(2):253-259. doi:10.1080/02791072.2003.10400007

11. Martin SA, Chiodo LM, Bosse JD, Wilson A. The Next Stage of Buprenorphine Care for Opioid Use Disorder. Ann Intern Med. 2018;169(9):628-635. doi:10.7326/m18-1652

12. Substance Abuse and Mental Health Services Administration. Practical Tools for Prescribing and Promoting Buprenorphine in Primary Care Settings. Published online 2021. Accessed June 3, 2025. https://library.samhsa.gov/sites/default/files/pep21-06-01-002.pdf

13. American Society of Addiction Medicine. Unobserved (Home) Induction Clinic Protocol. Accessed April 25, 2025. https://www.asam.org/docs/default-source/education-docs/unobserved-home-induction-clinic-protocol.pdf?sfvrsn=6224bc2_0

14. León-Barriera R, Zwiebel SJ, Modesto-Lowe V. A practical guide for buprenorphine initiation in the primary care setting. Cleve Clin J Med. 2023;90(9):557-564. doi:10.3949/ccjm.90a.23022

15. Hall OT, Entrup P, Farabee K, et al. The Perceived Role of Withdrawal in Maintaining Opioid Addiction among Adults with Untreated Opioid Use Disorder: A Survey of Syringe Exchange Program Participants. Substance Use & Misuse. 2024;59(2):312-315. doi:10.1080/10826084.2023.2269571

16. Elkins C. What Does Heroin Feel Like? Drug Rehab. 2020. Accessed April 4, 2025. https://www.drugrehab.com/addiction/drugs/heroin/what-heroin-feels-like/

17. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders (DSM-5). American Psychiatirc Publishing. Published online 2013. doi:10.1176/appi.books.9780890425596

18. Blevins D, Bramlette E, Burns A. Practice-Based Guidelines: Buprenorphine in the Age of Fentanyl. Providers Clinical Support System (PCSS); 2023. Accessed May 2, 2025. https://pcssnow.org/wp-content/uploads/2023/05/PCSS-Fentanyl-Guidance-FINAL-1.pdf

19. Grande LA, Cundiff D, Greenwald MK, Murray M, Wright TE, Martin SA. Evidence on Buprenorphine Dose Limits: A Review. J Addict Med. 2023;17(5). doi:10.1097/ADM.0000000000001189

20. Cleary EN, Rollins AL, McGuire AB, Myers LJ, Quinn PD. Buprenorphine discontinuation and utilization of psychosocial services: a national study in the Veterans Health Administration. Addiction Science & Clinical Practice. 2025;20(1):35. doi:10.1186/s13722-025-00562-1

21. Santo T, Clark B, Hickman M, et al. Association of Opioid Agonist Treatment With All-Cause Mortality and Specific Causes of Death Among People With Opioid Dependence: A Systematic Review and Meta-analysis. JAMA Psychiatry. 2021;78(9):979-993. doi:10.1001/jamapsychiatry.2021.0976

22. Skeie I, Clausen T, Hjemsæter AJ, et al. Mortality, Causes of Death, and Predictors of Death among Patients On and Off Opioid Agonist Treatment: Results from a 19-Year Cohort Study. Eur Addict Res. 2022;28(5):358-367. doi:10.1159/000525694

23. Williams AR. MOUD saves lives, especially after 60 days, and the longer the better. Addiction. 2022;117(12). doi:10.1111/add.16043

24. Hayes V, Mills L, Byron G, et al. Characterizing withdrawal from long-acting injectable buprenorphine: An observational case series. Drug Alcohol Depend Rep. 2025;15. doi:10.1016/j.dadr.2025.100329

25. Faysal JA, Noor-E-Alam Md, Young GJ, Yaseliani M, Goodin AJ, Hasan MM. Impact of telehealth, in-person, and hybrid care modalities on buprenorphine discontinuation among patients with opioid use disorder: A retrospective cohort study on commercially insured individuals. J Subst Use Addict Treat. 2025;176:209749. doi:10.1016/j.josat.2025.209749

26. Harris R, Stracker N, Rice M, St. Clair A, Page K, Rosecrans A. Redefining low-threshold buprenorphine access in an integrated mobile clinic program: Factors associated with treatment retention. J Subst Use Addict Treat. 2025;169:209586. doi:10.1016/j.josat.2024.209586

27. Axeen S, Pacula RL, Merlin JS, Gordon AJ, Stein BD. Association of Daily Doses of Buprenorphine With Urgent Health Care Utilization. JAMA Netw Open. 2024;7(9):e2435478. doi:10.1001/jamanetworkopen.2024.35478

Next Steps

Mitigating Overdose Risk

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Prescribing Case Examples: Choosing and Managing MOUD

Prescribing Case Examples

Medication Comparison Chart

Table References

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Phase I: Starting Medication (i.e., Induction)

Choice of Medication

Approaches to Starting Buprenorphine

Managing Withdrawal Symptoms

Phase II: Stabilization

Phase III: Maintenance

Medication Management Visits

.do_no_do_icon-1{fill:#2a7893;}.do_no_do_icon-2{fill:#d7eaef;} Avoiding Common Pitfalls

Resources

References

North Star

How Do You Do It?

Avoiding Common Pitfalls