Sandbox vidit

Induction: (day 1)

Identify the opioid's the patient has been using

Short acting opioids

Long acting opioids

❑ Discontinue short acting opioids ❑ Look for withdrawal symptoms (12-24 hours after last dose)

❑ Taper long acting opioids ❑ Methadone to ≤ 30 mg/day ❑ LAAM to ≤ 40 mg/48 hours ❑ Look for withdrawal symptoms: ❑ For methadone: 24+ hours after last dose ❑ For LAAM: 48+ hours after last dose

Withdrawal symptoms present: ❑ Administer buprenorphine/naloxone 4/1 mg ❑ Observe for 2+ hours

Withdrawal symptoms absent: ❑ Reevaluate the suitability for induction

Withdrawal symptoms present: ❑ Administer buprenorphine 2 mg ❑ Observe for 2+ hours

Withdrawal symptoms not relieved: ❑ Repeat buprenorphine 4mg (up to maximum of 8mg/24 hours ❑ Naloxone 1 mg (up to maximum of 2 mg/24 hours)

Withdrawal symptoms relieved: ❑ Day 1 dose established ❑ Send patient home ❑ Schedule patient to return on day 2 for forward induction

Withdrawal symptoms not relieved: ❑ Repeat buprenorphine 2mg (up to maximum of 8mg/24 hours)

Withdrawal symptoms relieved: ❑ Day 1 dose established ❑ Send patient home ❑ Schedule patient to return on day 2 for forward induction

Withdrawal symptoms not relieved: Manage withdrawal symptoms symptomatically ❑ Clonidine 0.2 mg every 4 hours, tapered after day 3, or ❑ Lofexidine 0.2 mg BD daily, titrated to 1.2 mg BD daily ❑ Chlordiazepoxide as needed ❑ Return next day for repeat induction attempt

Induction-day 2 forward

On return withdrawal symptoms absent: ❑ Administer a daily dose established equal to total buprenorphine & naloxone administered on previous day

On return withdrawal symptoms present: ❑ Administer dose equal to total amount of buprenorphine & naloxone administered on previous day + 4mg of buprenorphine (up to maximum of 12mg on day 2) & 1mg of naloxone (up to maximum of 3mg on day 2) ❑ Observe 2+ hours

Withdrawal symptoms relieved: ❑ Daily buprenorphine & naloxone dose established

Withdrawal symptoms not relieved: ❑ Administer buprenorphine 4 mg (up to maximum of 16mg on day 2) & naloxone 1 mg (up to maximum of 4 mg on day 2)

Withdrawal symptoms relieved: ❑ Daily buprenorphine & naloxone dose established

Withdrawal symptoms not relieved: Manage withdrawal symptoms symptomatically ❑ Clonidine 0.2 mg every 4 hours, tapered after day 3, or ❑ Lofexidine 0.2 mg BD daily, titrated to 1.2 mg BD daily ❑ Chlordiazepoxide as needed ❑ On subsequent induction days, if the patient returns experiencing withdrawal symptoms, continue increasing dose (up to a maximum of buprenorphine 32 mg/day & naloxone 8 mg/day

Stabilization phase (1-2 months): ❑ Transition when patient has: ❑ No withdrawal symptoms ❑ Minimal or no side effects ❑ No uncontrollable craving for opioid agonists ❑ Begin with buprenorphine/naloxone combination, increasing dose by 2/0.5-4/1 mg per week till stabilization is achieved, most stabilizing at 16/4-24/6 mg ❑ As patient stabilizes, transition to alternate day or every third day regimen by doubling and tripling daily doses respectively

Maintenance phase: ❑ Maintain at same dose as daily stabilization dose ❑ Decide total treatment duration based on: ❑ Stable housing & income ❑ Patients motivation, doctors comfort in tapering ❑ Presence of psychosocial support ❑ Absence of legal support ❑ Other drugs & alcohol abuse