Question 1

A 32-year-old man with opioid use disorder presents to your clinic requesting buprenorphine treatment. He has been using illicit fentanyl daily. His last use was 14 hours ago. He reports mild anxiety but says "I feel okay." His COWS score is 5. He asks you to start buprenorphine today because he is motivated to stop using. What is the most appropriate action?

Accepted Answer

Answer A ignores the COWS score and relies on time since last use, which is unreliable with fentanyl. This is the most dangerous answer, as precipitated withdrawal would likely drive this motivated patient out of treatment. Answer C (precipitating withdrawal with naloxone to "speed up" the process) is not standard practice for buprenorphine induction and would be intensely unpleasant. Answer D is not wrong as a treatment option (methadone does not require withdrawal before initiation), but it doesn't address what he asked for, requires referral to an OTP, and isn't necessary when buprenorphine can be started with appropriate timing or micro-dosing. The teaching point: time since last use is unreliable with fentanyl; use objective withdrawal scoring, and when in doubt, consider micro-dosing.

Question 2

A patient on buprenorphine/naloxone 16mg/day maintenance asks why the medication contains naloxone. She says she has been taking it sublingually as prescribed for 6 months. Why is the naloxone included, and is it affecting her treatment?

Accepted Answer

Answer A is incorrect: the naloxone is not an overdose protection mechanism (buprenorphine's own ceiling effect provides the safety feature). Answer C reverses the roles (buprenorphine is the active treatment). Answer D is a common misconception; at sublingual doses, naloxone is not systemically active enough to block buprenorphine's effects. The teaching point: understand the route-dependent bioavailability of naloxone in the combination product.

Question 3

A patient maintained on buprenorphine/naloxone 16mg/day requires emergency appendectomy. The surgical team plans to manage post-operative pain with IV hydromorphone. The patient's OUD provider is unavailable. What should the treatment team understand about pain management in this patient?

Accepted Answer

Answer A oversimplifies: stopping buprenorphine does not immediately clear the receptor (long half-life, high affinity), and abruptly stopping raises relapse risk. Answer C is dangerous (giving naloxone to a buprenorphine-maintained patient would precipitate withdrawal and create an acute pain crisis). Answer D is incorrect and inhumane: patients on buprenorphine absolutely deserve adequate pain management; it just requires a different strategy. The teaching point: buprenorphine-maintained patients represent one of the most clinically challenging acute pain scenarios, requiring multimodal approaches and interdisciplinary coordination.

Buprenorphine/Naloxone

Side Effects Worth Knowing

Constipation: common

Headache: common

Nausea/vomiting: common during induction

Insomnia: reported

Sweating: common

Precipitated withdrawal (induction): consequence of incorrect timing

Respiratory depression: substantially reduced risk compared to full agonists

Hepatic effects: rarely reported

Dental effects: FDA warning (2022)

See This Medication in Action

References & Further Reading