Brief Answer: Explained below. Detailed Answer: Hi Doctor, Welcome to Healthcare Magic! Before starting Suboxone, please ensure that the patient has been on this dose (25 mg per day) of methadone for at least two weeks. If it is possible to reduce methadone to 20 mg per day and wait for two more weeks before starting Suboxone, that will be even better. Once the patient is stable on the current dose of methadone and is not having any withdrawal symptoms, then you should stop the methadone. The patient should ideally be admitted for a few days. After the patient has been off methadone (and all opioids) for at least 36 hours, assess the patient for any withdrawal symptoms. It may take up to three to four days for the withdrawal to start. You can take the help of opioid withdrawal rating scales like COWS (freely available online) for confirmation. Buprenorphine is started only when patient is in withdrawal to ensure that there is no risk of precipitated withdrawal. Subutex (only buprenorphine) would be better than Suboxone for the first few days for the same reason, as naloxone in the Suboxone may precipitate withdrawal. When you start buprenorphine, give 2 mg first and observe the patient for around 2 hours. If the withdrawal symptoms are managed with this dose, then this is the required dose and should be continued from the next day onwards. If not, the dose may be repeated and observe for two more hours. A maximum of 8 mg in 24 hours can be given safely. If even that dose is not sufficient, then you will need to add other medicines like clonidine to manage the discomfort. If the required dose has been set on day 1, then it should be continued from next day onwards as a single dose in the morning. If the dose was not enough, then give the previous day's total dose in the morning of day 2 and add 2 mg more. Again observe and repeat the 2 mg dose if needed. Do not give more than 16 mg buprenorphine on Day 2. If the required dose is not reached even on Day 2, then on day 3, give the previous day's total dose in the morning and add 2 mg more. Again observe and repeat the 2 mg dose if needed. Do not give more than 24 mg buprenorphine on Day 3. The process continues. A maximum for 32 mg buprenorphine per day can be given, though I expect your patient will need much less than that. You can switch to the same dose of Suboxone from Subutex after arriving at the required dose. I hope this is helpful. Please let me know if you need more information. Best wishes. Dr Preeti Parakh MD Psychiatry

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