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Buprenorphine Treatment Algorithm

Revised September 2018

Diagnosis of Moderate to Severe Opioid Use Disorder

Assess for opioid type and last use

Patients taking methadone may have withdrawal reactions to buprenorphine up to 72 hours after last use. Consider consultation before starting buprenorphine in these patients.


(0-7) none - mild withdrawl


(>8) mild - severe withdrawl


None in ED


Waivered provider able to prescribe buprenorphine?



Unobserved buprenorphine induction and referral for ongoing treatment

Referral for ongoing treatment


4-8mg SL*


Observe for 45-60 min
No adverse reaction


If initial dose 4mg SL repeat 4mg SL for total 8mg 


Observe **


Waivered provider able to prescribe buprenorphine?



Prescription 16mg dosing for each day until appointment for ongoing treatment

Consider return to the ED for 2 days of 16mg dosing (72-hour rule)
Referral for ongoing treatment

All Patients Receive:

  • Brief Intervention
  • Overdose Education
  • Naloxone Distribution


*Clinical Opioid Withdrawal Scale (COWS) > 13 (Moderate-Severe) consider starting with 8 mg buprenorphine or buprenorphine/naloxone SL

**Patient remains in moderate withdrawal may consider adding additional 4mg and observation for 60 minutes

***May consider high dosing (total of 24-32mg) in consultation with an Addiction Specialist if the patient will not have access to buprenorphine >24 hours.

Warm hand-offs with specific time & date to opioid treatment providers/ programs within 24-72 hours whenever possible

All patients should be educated regarding dangers of benzodiazepine and alcohol co-use

Ancillary medication treatments with buprenorphine induction are not needed 

This page was last updated September 2018