Buprenorphine:Everything You Need to KnowBuprenorphine, a medication that is FDA-approvedfor addiction treatment and pain relief, has alsobeen found to dramatically decrease death ratesfrom opioid overdose. Only 10% of patients needingtreatment, however, have access to the medication.This document provides answers to frequently askedquestions about buprenorphine and supplements theCalifornia Health Care Foundation (CHCF) webinars“Expanding Access to Buprenorphine in PrimaryCare Practices” and “Is Buprenorphine for Pain aSafer Alternative to High-Dose or Long-Term OpioidUse?”1, 2 The clinical information contained in this paperis intended to act as a guideline, not a replacement foronsite medical judgment. Based on information covered in the CHCF webinars, the content was reviewedby addiction specialists Howard Kornfeld, MD, JamesGasper, PharmD, and Andrew Herring, MD.BackgroundOCTOBER 2016others are FDA-approved for pain (injectable, patch, andbuccal mucoadhesive film).Per the Drug Addiction Treatment Act of 2000 (DATA2000), physicians need a waiver to prescribe buprenorphine for addiction; attendance in an eight-hourin-person or online course is required to obtain a waiver.The Comprehensive Addiction and Recovery Act of 2016allows nurse practitioners and physician assistants to prescribe buprenorphine treatment after 24 hours of certifiedtraining. Clinicians are capped at 30 patients the first yearand 100 patients per year thereafter. The cap increasesto 275 patients for physicians board-certified in addiction, or those in practices that meet certain qualifications:24-hour call coverage, use of health information technology, provision of care management services, registrationwith CURES (Controlled Substance Utilization Review andEvaluation System, California’s prescription drug monitoring database), and acceptance of third-party insurance.Patients using buprenorphine for pain relief and notaddiction are not included in federal cap requirements.Buprenorphine is an opioid medication approved by theFood and Drug Administration (FDA) for treatment ofopioid dependence and for acute and chronic pain. It isa partial opioid agonist, meaning that it acts on certainopioid receptors in the brain, providing potent relief frompain and from opioid withdrawal symptoms, while actingas an antagonist on other opioid receptors, resulting inits unique pharmacology.3Any provider licensed by the Drug EnforcementAdministration (DEA) (e.g., physician, nurse practitioner, physician assistant) can prescribe buprenorphinefor pain. As a Schedule III drug, buprenorphine can beordered by phone or fax, and refills can be included onthe original prescription. In contrast, Schedule II drugs,such as hydrocodone, require tamperproof prescriptionsand one-month supply limits with no refills.Buprenorphine has a “ceiling effect” on respiration;that is, increasingly higher doses do not affect breathing in the same way that other opioids do. Deaths dueto buprenorphine overdoses are rare and usually involvemultiple medications (e.g., benzodiazepines, alcohol,other opioids or intravenous use). Some formulations(higher dose sublingual tablet, sublingual film, andimplant) are FDA-approved for opioid use disorder, whileTreatment with buprenorphine has been proven effectivein opioid addiction, decreasing mortality by approximately 50%. Patients treated with buprenorphine showimproved social functioning with increased retention intreatment (67% at one year) compared to drug-free treatment (7% to 25% at one year), reduced criminal activity,lower rates of illicit substance abuse, and reduced risk ofHIV and hepatitis infection.4 - 8Buprenorphine: Everything You Need to Know1

Buprenorphine is a potent pain reliever with particularadvantages for patients with chronic pain or pain complicated by opioid dependence. Although traditionalpractice has been to discontinue buprenorphine duringhospital admissions, new research shows that buprenorphine can be continued when patients are admitted tothe hospital, with pain controlled by other opioids usedon top of the baseline buprenorphine regimen.9 -11 Studiesof patients on high-dose opioids transitioned to sublingual or buccal buprenorphine have shown improved paincontrol, improved control of psychiatric symptoms, andmuch lower risk of overdose death.12,13Patients commonly start buprenorphine in a clinician’soffice after 12 to 48 hours of withdrawal symptoms —a process known as an induction — since sublingualbuprenorphine often causes severe withdrawal symptoms if started shortly after use of other opioids. Patientswith pain diagnoses can avoid these symptoms, however,by using a fentanyl or buprenorphine patch, which minimizes or eliminates withdrawal symptoms.14 It should benoted that these patches are FDA-approved for pain, notaddiction: A DEA letter clarified that there is no restriction on the use of buprenorphine for pain relief (evenfor the high-dose sublingual formulations approved foraddiction and prescribed off-label for pain).15 To increaseconvenience for the patient and decrease the burdenon the office practice, home inductions are now in morefrequent use; in these cases, the patient is given instructions on when to take the first dose and how to monitorwithdrawal symptoms.California does not have adequate buprenorphine prescribers to meet the growing demand for treatment.As a result, only 10% of those needing opioid addiction treatment with buprenorphine are able to accessit. Buprenorphine remains inaccessible to most patientswith addiction or chronic pain due to many obstacles:not enough waivered physicians, lack of understandingabout its use, the paperwork burden from health planauthorization requirements and from tracking patients tostay under the cap limit. To overcome these obstacles, in2015 Medi-Cal removed authorization requirements frombuprenorphine sublingual and patch formulations.California Health Care FoundationPublished Studies on BuprenorphineThe following are important studies on buprenorphine’s effectiveness in treating opioid addiction:randomized, controlled study from Swedencompared detox plus placebo to detox plusmaintenance buprenorphine: 4 out of 20(20%) died of overdose in the first year in theplacebo group, compared to 0 deaths in thebuprenorphine group.16 A Patientson opioid maintenance therapy(buprenorphine or methadone) are less likelyto contract hepatitis C and HIV.17,18than 9 of 10 people continue to useopioids after an overdose event. An overdoseshould be a signal that the patient is at highrisk of death, immediately triggering a plan totaper to a safer regimen of prescribed opioids,offer take-home naloxone, or consider addiction treatment (buprenorphine or methadone)when appropriate.19 More ThePrescription Opioid Addiction TreatmentStudy (POATS) trial evaluated short- andlong-term buprenorphine treatment. Of thosepatients tapered off at 12 weeks, 9% reportedabstinence compared to 50% of those continuing treatment. Patients using buprenorphinewere more than twice as likely to reportabstinence at 18 months compared to thosewho were not using buprenorphine (80% versus37%); the difference persisted at 42 months(80% versus 51%).20California does not have adequatebuprenorphine prescribers tomeet the growing demand fortreatment.2

Clinical QuestionsInduction OptionsShould patients be induced in a clinic or at home?Induction is the process of switching to buprenorphinefrom other opioids; physicians typically require thatpatients experience 12 to 48 hours of withdrawal symptoms before starting buprenorphine. Clinical trials onbuprenorphine have been performed with observed (inoffice) inductions, and many clinic protocols are basedon this practice. However, home induction is increasinglyused, both to improve clinic workflow and to increaseconvenience for the patient. Some clinics do home inductions exclusively; others adapt the strategy to the needsof the patient, using home inductions for stable patientsand clinic inductions for those needing closer monitoring(e.g., psychiatric instability).What are induction clinics? Induction clinics relieveprimary care practices of the intensity and frequency ofvisits for patients newly starting on buprenorphine. Theseclinics can devote time and staff resources to intake,assessment, evaluation of options, education, induction,and early monitoring. The patients can be transferredback to primary care when they are stable on monthlyprescriptions. This approach has been used successfullyfor over 10 years in San Francisco at the Office-BasedOpioid Treatment Induction Clinic. A similar “hub andspoke” model is used in Vermont, where complexpatients go to the hub (an opioid treatment program)and stable patients are managed at the spokes (primarycare practices).21What is a buprenorphine or fentanyl patch induction?A buprenorphine or fentanyl patch can bridge a patientfrom their current opioid treatment to sublingual buprenorphine, without requiring the patient to experience 12 to48 hours of withdrawal symptoms. Buprenorphine andfentanyl patches are not FDA-approved for addictionunder DATA 2000 and should only be used for patientswho have been diagnosed with chronic pain.The following guidelines, based on Dr. Kornfeld’sresearch and practice, are not intended to replace medical judgment.22, 23 Patients should be assessed every 1 to2 days, and adjustments made as needed. Expert adviceis widely available (see accompanying sidebar).Where Can Clinicians Get Trainingand Support?Buprenorphine trainings are offered at several locations and websites. The training takes about eighthours and can be attended in person, online, or acombination of both. Buprenorphine waiver trainingcan be valuable to any clinician (medical or behavioral) as it covers the basics of opioid addiction andhow buprenorphine works.Clinicians can only prescribe buprenorphine foraddiction after receiving certified training and aDrug Enforcement Administration (DEA) waiver.However, any DEA-licensed clinician can prescribebuprenorphine for pain.Training opportunities are posted on the followingwebsites: Substance Abuse and Medical Health Services Administration (SAMHSA),American Academyof Addiction Psychiatry (AAAP), American Osteopathic Academy of Addiction Medicine (AOAAM),and Providers’ Clinical Support System (PCSS).24 - 27Some sites also offer other tools and resources.PCSS offers online mentorship, and Project ECHO28offers video telementoring and monthly case review.The Clinicians Consultation Center at UCSF offersexpert clinical advice, Monday through Friday,7 a.m. to 3 p.m. PST.29Substance Use Warmline: (855) 300-3595.Buprenorphine Transdermal (Patch) InductionSTEP 1. Taper off methadone. Because methadoneexits the body slowly, especially at high doses, mostaddiction treatment protocols advise a gradual taperto 30 mg of methadone, followed by abstinence for48 hours or longer, before administration of sublingualbuprenorphine. Unlike patients with addiction alone,patients with an accompanying diagnosis of chronic paincan use buprenorphine patches and other opioids for aneasier transition and fewer withdrawal symptoms.First, convert methadone to a different long-acting opioid(morphine, oxycodone, hydromorphone, hydrocodone,or oxymorphone). Due to individual variability, use caution when calculating the morphine equivalent dose: Use30% to 50% less than the dose calculated by any conversion calculator, and prescribe only a small quantity of pillsat a time.Buprenorphine: Everything You Need to Know3

50mg methadone: Use long-acting opioid for 3to 4 days before starting the buprenorphine patch. 50to 100 mg methadone: Replace half of methadone with long-acting opioid for 3 to 4 days, thenreplace the other half for 3 to 4 days (overlappingor cross-taper). 100mg methadone: Use the cross-taper methodin three or more steps. Afterappropriate time on long-acting opioid,proceed to step 2.STEP 2. Buprenorphine patch induction for patientson long-acting opioids. Before the induction day, prescribe the following medications and ask the patient tobring all to the office: Buprenorphinepatches (one 20 mcg/hour, two10 mcg, or four 5 mcg patches. (One box containsfour patches, though pharmacists sometimesdispense less than a box.) Each patch lasts oneweek. Usually, transdermal buprenorphine is onlyneeded for a few days to a week during theinduction phase. Buprenorphinesublingual 2 mg #12-30 (amountdepends on patient stability). The buprenorphine mono product — without naloxone — isless expensive with similar efficacy, though manyclinicians use the combination product, buprenorphine/suboxone, to prevent diversion andinjection use (the evidence is unclear whether thiscombination product prevents diversion).30 - 32 Fourdays of short-acting opioids (30% to 50% lessthan the current long-acting opioid dose). Optionsinclude immediate release forms of morphine,oxycodone, hydrocodone, or hydromorphone.STEP 3. Start sublingual buprenorphine. After3 to 4 days on the patch, discontinue theshort-acting opioids the night before starting sublingual buprenorphine. Keep the patch in place. Give1 mg (half-tablet) buprenorphine in theoffice; have the patient wait for 30 minutes toobserve the effect before going home (observedinduction is recommended for pain patients). Thepatient can take another 1 mg dose later that day. Increasedose by 2 to 4 mg every 3 days, asneeded to control pain and cravings, to a maximum of 24 mg. Some physicians titrate up at afaster pace, though many patients do well onlower doses. Theslow onset of the buprenorphine deliveredthrough the patch system should prevent precipitated withdrawal. Once higher doses of sublingualbuprenorphine are tolerated, discontinue thepatch.Fentanyl Transdermal (Patch) Induction Transitionpatients from their current opioidregimen to fentanyl 25 or 50 mcg; continue for3 to 7 days. Discontinueany short-acting opioids (if used) atleast 24 hours prior to sublingual buprenorphine. Removefentanyl patch and give 1 to 2 mg sublingual buprenorphine; observe for 20 minutes. Increaseto 8 mg if needed to manage withdrawalsymptoms on the first day, and up to 24 mg over3 to 7 days, as needed.Instruct the patient to stop taking long-acting opioids thenight before the induction. Short-acting opioids can beused as needed for pain.Simultaneously (on the first day of the induction): Place20 mcg/hour of buprenorphine patch(10 mcg/hour for very low dose conversions).Keep patch on for 3 to 4 days. Continueshort-acting opioids as needed for pain.California Health Care Foundation4

Behavioral Health and OtherAddiction TreatmentsWhat behavioral health treatments are required bythe DEA waiver? The standard of care for opioid usedisorder requires that patients be offered medicationsand behavioral health treatment. Although the waivermandates clinicians to offer referrals to behavioral healthservices, patients are not required to accept them, andthese services do not have to be located onsite or delivered in-person.Two studies are reassuring for communities with insufficient behavioral health resources: One randomizedcontrolled trial showed that buprenorphine is effectiveeven without behavioral counseling.33 A 2016 AmericanSociety of Addiction Medicine (ASAM) review foundmixed support in the literature for behavioral healthinterventions for opioid addiction.34 Nevertheless, mostexperts recommend a comprehensive (medical andbehavioral) approach where available. Addiction is achronic illness that requires lifestyle changes. Behavioraland social therapies, as a supplement to medicationtreatment, can increse success in recovery.How long do patients have to be in treatment beforethey are considered drug-free? Patients participating inbuprenorphine treatment while simultaneously avoidingother illicit substances are considered clean and soberby addiction specialists. Addiction specialists now consider opioid use disorder to be a chronic disease, andthis perspective informs treatment. Instead of discontinuing treatment when the patient has relapses or slips, anappropriate response is now to increase the intensity ofmonitoring.How does buprenorphine compare to methadone?Buprenorphine and methadone have both been proveneffective in opioid addiction.35 Methadone has beenshown to have a slightly higher retention rate in treatment, but it is unclear if this result is due to the medicationor due to the wrap-around behavioral health services andthe close monitoring that are components of methadoneprograms.Methadone is better suited for patients who have psychiatric instability, addiction to multiple substances, or otherconditions that require close monitoring. Buprenorphinehas several advantages: It is available in primary caresettings, it can be given to stable patients with followup once a month or every three months, and its partialagonist properties help prevent overdose death. Fora recent review of the evidence for treatment options,see the Vancouver Health Authority Opioid AddictionGuidelines, which recommends buprenorphine as firstline treatment and methadone for patients failing trials ofbuprenorphine.36Conversion, Tapers, and DosageHow should patients be converted from buprenorphine to another opioid and vice-versa? Buprenorphineis a very potent opioid. As a precautionary measure, afactor of 30:1 to 90:1 (morphine milligram equivalents tobuprenorphine) is used when converting from other opioids to buprenorphine. Conversion from buprenorphineto other opioids must also be approached cautiously, ata much lower conversion ratio. Buprenorphine leaves thebody slowly. If a full agonist treatment is used, it shouldbe started at a low dose and increased gradually, as thebuprenorphine wears off. When treating addiction withbuprenorphine, the target maintenance dose is 16 mgper day and does not use a conversion factor — the dose“We have to adopt a different perspective. For pain meds, we don’t refill early, and we tryto cut doses down. For addiction, we may do early refills and dose increases if cravingand symptoms are not controlled. Likewise, we don’t cut people off buprenorphine whenthey use marijuana or other drugs — we shouldn’t stop an effective treatment because thepatient has more than one problem.”— Gary Pace, MD, medical director, Alexander Valley Medical CenterBuprenorphine: Everything You Need to Know5

is based on the need to control cravings and preventrelapse, and the opioid dose used during active addiction is not relevant.Should patients always be tapered off buprenorphine?Although buprenorphine can be used in short-termdetoxification programs, addiction experts increasinglydiscourage this approach and instead encourage continuing buprenorphine long-term.37 Patients who stopbuprenorphine during the first few months of theirtreatment experience high rates of relapse, even withintensive behavioral support.38 In a 2015 long-termtreatment study, only 9% of patients remained abstinent after buprenorphine taper, while 80% of patientsreported abstinence at 18 months and 42 months if theycontinued daily buprenorphine treatment.39 Withoutlong-term treatment, patients often return to the drugto which they were addicted, and the dose (or fractionof the dose) their bodies tolerated prior to treatment canlead to overdose death. Detoxification and tapering withbuprenorphine is still superior to providing no medication-assisted treatment at all, and can be considered incircumstances where timely follow up for continuation ofbuprenorphine is not available, or the patient specificallydesires detoxification.How does a physician taper a patient off buprenorphine?When tapering, smaller doses can be used by dividing2 mg tablets into smaller segments. If a patient has anaddiction by no chronic pain diagnosis, the smallest fraction that can be realistically achieved is ½ (1 mg) and ¼(0.5 mg) of a tablet. Buprenorphine tablets have muchlower bioavailability when swallowed compared to whenthey are absorbed sublingually, so swallowed buprenorphine tablets can be used in the latter stages of a taperto achieve lower doses. If the target condition is pain,then buprenorphine can be compounded by a specialtypharmacy to create low doses, or low doses of the buccal and patch formulations can be used. For example,one month of each strength of the buprenorphine patch(20, 15, 10, 7.5, and then 5 mcg/hour) is one effectivemethod of gradually tapering buprenorphine to 0 in apain patient.Should physicians discontinue buprenorphine treatmentfor patients who are using marijuana, methamphetamine, or other drugs? Marijuana use has not beenshown to worsen outcomes for patients on buprenorphine for opioid use disorder.40 The California Society ofAddiction Medicine recommends continuing buprenorphine and treating patients for marijuana use disorder,Table 1: Buprenorphine Formulations and DosagesFORMULATIONDOSES AVAILABLEINDICATIONParenteral(Buprenex)0.3 mg IV/IM q 30 minutes, duration 6 to 8 hoursPainTransdermal patch (Butrans)buprenorphine: 5, 7.5, 10, 15, and 20 mcg/hour, every 7 daysPainLow-dose buccal mucoadhesive film(Belbuca)buprenorphine: 75, 150, 300, 450, 600, 750, 900 mcg, twice dailyPainHigh-dose buccal film(Bunavail)buprenorphine/naloxone, daily: 2.1 mg/0.3 mg, 4.2 mg/0.7 mg,and 6.3 mg/1 mgAddictionSublingual tablets(generic subutex, generic suboxone,generic zubsolv)Dosed daily for addiction; divided doses for painAddictionGeneric subutex: buprenorphine: 2 mg, 8 mgPain (off-label)Analgesic equivalent 10 mg IV morphine for opioid naïvePain (off-label)Generic suboxone/zubsolv: buprenorphine/naloxone:2 mg/0.5 mg, 8 mg/2 mg; 1.4 mg/0.36 mg, 2.9 mg/0.71 mg,5.7 mg/1.4 mg, 8.6 mg/2.1 mg, 11.4 mg/2.9 mgSublingual film(Suboxone)buprenorphine/naloxone: 2 mg/0.5 mg, 4 mg/1 mg, 8 mg/2 mg,12 mg/3 mgAddictionImplant80 mg (equivalent to 8 mg sublingual daily)AddictionPain (off-label)Pain (off-label)CompoundedCalifornia Health Care FoundationMany options from low to high dosesPain6

if present. Patients may have more than one addiction:Buprenorphine may successfully treat opioid use disorder,while patients continue to need behavioral treatments forother active addictions to drugs, such as methamphetamine or cocaine. Patients with addictions to multiplesubstances may benefit from the intensive treatment ofan opioid treatment program, if available. If such programs are not available, these patients will be less likely tooverdose, contract an infection, or have another negativeoutcome if treated with buprenorphine than they wouldbe on other opioids or street alternatives (common pathways when opioid treatment is abruptly discontinued).What dosage formulations are available? Buprenorphineis a Schedule III drug (refills can be called in or faxed).Table 1 lists the formulations and dosages available. (Seepage 6.)Buprenorphine for Pain(Outpatient and Inpatient)Under what circumstances can buprenorphine be prescribed for pain? Any buprenorphine formulation canbe used for a patient with a pain diagnosis by any DEAlicensed clinician without a waiver. The DEA clarifiedthat “limitations and requirements [relating to addictiontreatment] in no way impact the ability of a practitionerto utilize opioids for the treatment of pain when actingin the usual course of medical practice. Consequently,when it is necessary to discontinue a pain patient’s opioid therapy by tapering or weaning doses, there are norestrictions with respect to the drugs that may be used.This is not considered detoxification as it is applied toaddiction treatment.”41If a patient has an addiction diagnosis but no diagnosis ofpain, the physician must have a DEA waiver and can onlyprescribe tablets, sublingual film (either buprenorphinealone or buprenorphine with naloxone), or the implant.Compared to other opioids used for pain relief, whatare the advantages of buprenorphine? Buprenorphineprovides excellent pain control, with no ceiling effectbelow 300 mg morphine equivalents. It has an excellent safety profile, due to a ceiling effect on respiratorysuppression. Buprenorphine’s onset of action is 30 to 60minutes, and it typically provides 8 hours of pain relief,so it is usually given in divided doses when used for painunless the patch formulation is used.Buprenorphine, unlike other long-acting opioids, has relatively few drug/drug interactions and does not accumulatein patients with renal impairment. Due to long half-life,partial agonist activity at the mu receptor, and antagonismat the kappa receptor, common medical problems resulting from other long-acting opioids arise less frequentlywith buprenorphine.42 These problems include: sleepapnea, low testosterone, sexual dysfunction, osteopenia,opioid-induced hyperalgesia, mood disorders (depression and anxiety), and dysregulation of the hypothalamicpituitary adrenal axis. A growing body of literature isfinding improved pain relief on buprenorphine after conversion from other long-acting opioids.43 - 46 For example,one study of 35 patients found a mean decrease in painscore from 7.2 to 3.5, with 34 out of 35 patients reporting a pain decrease.47 A Cochrane meta-analysis of cancerpain found that buprenorphine was superior to other opioids (5 out of 11 studies) or at least equivalent to otheropioids for pain relief (3 out of 11 studies).48How do physicians convince patients to transition fromother opioids to buprenorphine? Education about themedical side effects of opioids used over a long periodof time often helps patients understand the rationalefor change. Patients may be unaware that some of theirmedical problems are due to chronic opioid use and thatthese issues may resolve after the transition: Sedation,mood disorders (depression and anxiety), sleep apnea,and erectile dysfunction are some of the more distressing problems for patients. Education about hyperalgesiaand the common experience of withdrawal symptomsbetween doses may convince patients to make thechange. Some patients can be tapered off of antidepressants and neuroleptic drugs. Other patients are motivatedby the fact that buprenorphine is a Schedule III medication (refills can be called in), which mitigates patients’bureaucratic inconvenience in obtaining the drug.Should buprenorphine be prescribed for the elderly?For elderly patients already on long-term opioids, transitioning to buprenorphine lowers the risk of accidentaloverdose and potentially lowers the risk of medical complications (e.g., sleep apnea and hypogonadism). For thisreason, buprenorphine may be a safer choice for elderlypatients already on daily opioid treatment. For elderlypatients not currently taking opioids, the lowest doseof the buprenorphine-naloxone sublingual tablet formulation (2 mg) can be equivalent to 60 to 180 mg oralmorphine a day, depending on the patient’s metabolism,and would be too high a dose. Buprenorphine productsBuprenorphine: Everything You Need to Know7

in the form of a transdermal patch or buccal film come inmuch lower doses and can therefore be used for treatingelderly patients with no opioid tolerance.How should patients on buprenorphine be managedperioperatively or in the hospital? Some perioperativeprotocols still require buprenorphine to be discontinued,but this approach puts patients at risk for longer lengthsof stay and subjects patients to a risk of relapse and theneed for re-induction. Continuing buprenorphine, withadditional analgesia when needed, has been shownin recent studies to be an effective way of managinginpatient and perioperative pain.49 Additional doses ofbuprenorphine, or other opioids, can be given simultaneously with maintenance buprenorphine for satisfactorypain relief. In small cohorts, continuing buprenorphinelowered the length of hospital stay with better or equalpain control.50Can patients be induced on buprenorphine in theemergency department (ED)? Gail D’Onofrio, MD, MS,of Yale University, conducted a randomized controlledtrial of starting buprenorphine in the ED for addiction andfound that those given buprenorphine had twice the30-day retention rate in treatment (78%) compared withreferral to addiction treatment services (37%).51 If opioids are indicated for pain, buprenorphine can be a saferchoice for patients with active or historical substance use,and can be administered sublingually, by patch, by injection (intravenous or intramuscular) while in the ED, or astake-home doses after discharge.Some California EDs are now performing buprenorphine inductions while the patient is in the ED, or aregiving patients instructions for home induction, combined with expedited referral to outpatient treatment.CHCF works with emergency physicians interested inpiloting this treatment; for more information, contactCHCF’s director of High-Value Care Kelly Pfeifer, MD, [email protected] buprenorphine be used for pain in the ED?Buprenorphine used to treat pain (sublingual, buccal,transdermal, intravenous, or intramuscular forms) can beused in the ED by clinicians without a waiver. Advantagesof buprenorphine as a first-line opioid analgesic, whenopioids are indicated, include: lower abuse potential,lower risk for respiratory depression, and longer durationof pain relief.California Health Care FoundationBuprenorphine may be a better choice for people withactive or historical substance use disorders requiringopioid analgesia, as it would be less likely to triggerrelapse. As with all opioid analgesics, buprenorphineshould be used sparingly for pain after both nonpharmacologic interventions and nonopioid analgesics havefailed. Buprenorphine can be administered or prescribedfor pain by any clinical provider with DEA opioid-prescribing authority.Administrative QuestionsWhere can patients find buprenorphine-waiveredclinicians? Visit the SAMHSA treatment finder.How do physicians get buprenorphine approvedby medical insurance companies or Medi-Cal?What is a Treatment Authorization Request (TAR)?Medi-Cal does not require the

STEP 1. Taper off methadone. Because methadone exits the body slowly, especially at high doses, most addiction treatment protocols advise a gradual taper to 30 mg of methadone, followed by abstinence for 48 hours or longer, before administration of sublin