Buprenorphine Initiation: A Low-Dose Protocol for Long-Acting O/Fen

Scheduled ancillary TID/QID meds: Click for more information.

Serial VS/COWS. Click for more information.

Methadone-buprenorphine crossover: Click for more information.

Inpatient initiation: Provide patient-centered care/education on OUD, withdrawal management, MOUD.

Evaluation. Identify and refer urgent problems. History, laboratory, medical examination, prenatal care, mental health, psychosocial assessment, social, and environmental factors. Discuss treatment options, patient-centered "choice and voice," TIC, informed consent. Safety/efficacy with either buprenorphine+naloxone and burprenorphine. Plan for outpatient if stable and < 22-24 weeks or inpatient initiation if unstable and > 24 weeks.

Outpatient Initiation: Provide education on OUD fentanyl withdrawal management

Warm hand-off: encourage daily phone and office Q3-7d f/u, group/peer coach/ doula support, prenatal, mental health, psychosocial tx. Adjust bup in 2nd/3rd trim. Ongoing smoking cessation, overdose prevention/narcan.

Scheduled ancillary TID/QUID meds: Gabapentin 300mg, hydroxyzine 25-50mg, dicyclomine 20mg, tizanidine 2mg. Low dose buprenorphine: 0.5mgQ6Hx2 -> 2mgQ6Hx2 -> 4mgQ6Hx2 ->8mg BID/TID. D/c ancillary meds once stable dose.

Methadone-buprenorphine crossover: Day 1: Methadone 50mg-buprenex 0.15mg QID Day 2: Methadone 50mg-buprenex 0.30mg QID Day 3: Methadone 50mg-buprenex 0.60mg QID Day 4: Methadone 40mg-buprenorphine 1mg QID Day 5: Methadone 30mg-buprenorphine 2mg QID Day 6: Methadone 20mg-buprenorphine 4mg QID Day 7: Methadone 10mg-buprenorphine 8mg TID Scheduled/prn ancillary meds.

Serial VS/COWS. Scheduled ancillary gabapentin 300mg QID, hydroxyzine 50 mg QID, dicyclomine 20mg QID, tizanidine 2mg QID, mirtazapine HS. Start buprenorphine 0.15mg Q2-4Hx2 -> 0.30mg Q2-4Hx2 -> 0.60mg Q2-4Hx2 -> 1mg Q2-4Hx2 -> 2mg Q2-4H -> 4mg Q2-4Hx2 -> 8mg BID/TID, d/c ancillary meds once stable dose.