Starting Buprenorphine: What Induction Day Is Like and Why Timing Matters

Owen: Fentanyl has made timing questions more common. A 2024 study at three Philadelphia hospitals looked at patients who used fentanyl and then started buprenorphine.

Claire: Thanks for joining us. You're listening to Between Visits, sponsored by Hope Health Network, a network of medical practices serving South Carolina. We dig into the medical and mental health topics that matter most to patients and the public.

Claire: I'm Claire, and this is episode 6. I'm going to quickly play our disclaimers, and then we'll get started!

Recorded disclaimer: This show is for entertainment, education and general information only. It's not medical advice, and listening doesn't make you a patient. Our hosts and guests are not real people, medical doctors or healthcare providers. We do our best, but we can be wrong, and our content can have errors and omissions. Talk with a licensed medical provider in your state before you make any decisions about your health or medical care.

Claire: Joining me today is Owen, from our digital entertainment team. Today's topic is an important one: Starting Buprenorphine: What Induction Day Is Like and Why Timing Matters.

Claire: This can be a heavy subject. If it ever starts to feel like too much, at any point today, it's okay to step away. And help is always just a call away, any time, day or night. In an emergency, call 911. In a crisis, call or text 988.

Claire: Okay, Owen. Thanks for being here today.

Owen: Thanks, Claire. I'm glad we're talking about this.

Claire: Me too, Owen. Let's get started.

Claire: Today we're talking about starting buprenorphine. That's the medicine in Suboxone and other brands. If you're thinking about starting it, I bet the first day feels like a big unknown.

Owen: It can. Starting this medicine is a strong step toward recovery from opioid use disorder. And a good first day mostly comes down to timing.

Claire: Timing. Okay, we'll get to that. But first, I keep hearing a word. Induction. What does that mean?

Owen: It's just the medical word for starting buprenorphine. So induction day is the day you start.

Claire: That's simpler than it sounds. And what kind of medicine is it?

Owen: It's called a partial opioid agonist. That means it acts on the same parts of the brain as other opioids. But at low to moderate doses, its effects are weaker.

Claire: So it works in the same spot, just not as strongly.

Owen: That's a fair way to put it. The Substance Abuse and Mental Health Services Administration, a federal agency, says it can ease withdrawal symptoms and cravings. It also says it can lower the potential for misuse.

Claire: And Suboxone has something else in it, right? Naloxone?

Owen: Yes. Suboxone combines buprenorphine with naloxone. That same agency says naloxone is added to make misuse of the medicine less likely.

Claire: Okay. Let's go back to timing. Why can't a person just take the first dose as soon as they're ready?

Owen: The Food and Drug Administration label for Suboxone film gives two conditions. The first dose should be given when objective signs of moderate opioid withdrawal appear. And it should be not less than 6 hours after the last opioid use.

Claire: Objective signs. What does that mean in plain words?

Owen: Signs your provider can see or check, not only how you feel inside.

Claire: So it isn't only about how I feel. My provider is checking too.

Owen: Right. Your provider checks your withdrawal signs before the first dose.

Claire: But why wait at all? Withdrawal feels awful. I'd want the medicine as soon as I can get it.

Owen: That's a fair question. Because buprenorphine is a partial agonist, the label warns that it may bring on withdrawal if it's taken before the effects of another opioid have worn off.

Claire: Wait. The medicine for withdrawal can cause withdrawal?

Owen: It may, if it's taken before the other opioid has worn off. That's called precipitated withdrawal. It means withdrawal set off by the new medicine, instead of by stopping.

Claire: Set off by the new medicine. Okay. So that's what the waiting is about.

Owen: Yes. That's why the label ties the first dose to those signs, and to that time since your last use.

Claire: So is 6 hours the goal? Set a timer, get to 6 hours, take the dose?

Owen: No. The 6 hours is a minimum, not a goal. Your provider sets the timing for you, based on what you used, how much and when.

Claire: A minimum, not a goal. So nobody should watch the clock and decide on their own.

Owen: Right. Those details are what your provider uses to set the timing.

Claire: What about someone who takes methadone? Is that different?

Owen: It can be. If you take methadone or another long-acting opioid, the label says you may be more likely to have precipitated withdrawal, and withdrawal that lasts longer, when starting.

Claire: So what does the label say to do?

Owen: For these patients, it recommends starting with buprenorphine alone, without naloxone.

Claire: Could someone make that switch by themselves?

Owen: Please don't. Make any switch with your provider, never on your own. And so it's clear, Hope Integrative Medicine, a member of Hope Health Network, does not prescribe methadone and is not a methadone clinic.

Claire: Good to know. Now, fentanyl. A lot of people listening may be wondering how that changes things.

Owen: Fentanyl has made timing questions more common. A 2024 study at three Philadelphia hospitals looked at patients who used fentanyl and then started buprenorphine.

Claire: And what did they find?

Owen: There were 226 hospital patients in the study. Of those, 11.5 percent developed precipitated withdrawal after starting. That's a little more than 1 in 10. Nearly 9 in 10 did not.

Claire: Nearly 9 in 10 did not. So does that mean fentanyl doesn't really matter?

Owen: No, I wouldn't say that. The researchers note that with regular use, fentanyl can build up in muscle and fat. They are still studying whether that buildup raises the risk of precipitated withdrawal.

Claire: So they don't have the full answer yet.

Owen: Right. That's why your provider asks exactly what you used and when. The plan may look different if fentanyl is part of the picture. Careful timing, planned with your provider, helps.

Claire: That can be a hard thing to say out loud, though. Exactly what you used, and when.

Owen: It can. But those answers are what your provider uses to time your first dose. So it helps to be specific.

Claire: Walk me through the day itself. What actually happens on induction day?

Owen: Expect honest, detailed questions. Your provider will ask about every substance you've used, including alcohol and sedatives. Sedatives are drugs that make you calm or sleepy. You'll also be asked the time of your last use of each one.

Claire: Every substance. Not just the opioids.

Owen: Every one. A urine drug or fentanyl test, done right there in the office, can add to the picture. Then your provider checks your withdrawal signs before the first dose.

Claire: And how do I take it? Do I just swallow it?

Owen: No. The first dose dissolves under the tongue. The label recommends that route during induction. It keeps naloxone exposure low and reduces the risk of precipitated withdrawal.

Claire: Okay, under the tongue. How much do I take?

Owen: The label describes starting with a small dose and adding more in steps on day 1. Then it's a single daily dose on day 2. Your provider decides the amounts.

Claire: And what if I take it and I feel worse?

Owen: Tell your provider right away. Please don't wait on that.

Claire: Tell them right away. Got it. What about after that? Day 3 and on?

Owen: The first days are about finding a dose that controls cravings and withdrawal. The label says that from day 3 on, the dose is adjusted up or down in small steps. That's to keep you in treatment and hold withdrawal down.

Claire: So it gets fine-tuned. It's not one dose and you're done.

Owen: Right. Plan on follow-up visits while your dose is being set. And be open about how you feel.

Claire: Are there safety rules while you're on it?

Owen: A few, from the Substance Abuse and Mental Health Services Administration. Do not use illegal drugs or drink alcohol. Do not take sedatives, tranquilizers or other drugs that slow breathing. If one is prescribed for you, don't stop it on your own. Tell your provider.

Claire: And what about keeping it at home?

Owen: Store it out of reach of children and pets. The label also asks patients and caregivers to learn about overdose reversal medicines, such as naloxone.

Claire: So the people at home should learn about that too, not just the person taking it.

Owen: Yes. The label asks caregivers to learn about it too.

Claire: How long do people stay on this? Is there an end date?

Owen: That same agency says the length of time is tailored to each patient. It also says medicines for opioid use disorder can be used long term.

Claire: So there isn't one timeline that fits everybody.

Owen: Right. That's a good talk to have with your provider.

Claire: If someone's getting ready for that first visit, what could they ask?

Owen: Here's one to bring along. Based on what I use and when I last used it, when should I take my first dose, and what should I do if I feel worse after it?

Claire: That really covers it. What I use, when I used it, and what to do if it goes badly.

Owen: It does. And one more thing, because it matters. In an emergency, including a possible overdose, call 911. If you or someone you know is struggling, call or text 988 to reach the 988 Suicide and Crisis Lifeline. It's also there for alcohol or drug use concerns.

Claire: Thank you for saying that. Okay, before we wrap up. If people only remember a few things from today, what should they be?

Owen: First, the 6 hours is a minimum, not a goal. The first dose waits for signs of moderate withdrawal that your provider can see or check.

Claire: Okay. What else?

Owen: Second, tell your provider exactly what you used and when, including fentanyl. The plan may look different because of it.

Claire: And one more?

Owen: If you feel worse after a dose, tell your provider right away. And if someone may be overdosing, call 911.

Claire: That's really helpful. Thank you for walking us through this.

Owen: Thanks for having me, Claire. I hope it helps someone.

Claire: This episode is sponsored by Hope Health Network. Its member practices all have providers experienced in managing opioid use disorder, or can refer you to a network provider who is. Hope Health Network medical practices provide evidence-based medical care and include Hope Integrative Medicine, Hope Medical Associates, Hope Behavioral Medicine and Hope Addiction Medicine. To learn more, go to Hope Health Network dot com. That website, along with appointment links for all four practices, is in the description of this episode.

Claire: One last reminder. In an emergency, call 911. In a crisis, call or text 988.

Claire: This podcast is a production of Hope Health Network Media.

Claire: You've been listening to episode 6 of Between Visits, Starting Buprenorphine: What Induction Day Is Like and Why Timing Matters. Thanks for hanging out with us. See you next time!