Standard ED Start
( They are kicking in front of you)

Step 1: Ask if they have taken "Suboxone" or "Bup" Before

If "Yes"and they had a good experience, just follow their wishes a provide whatever dose they request ( within reason ).


Step 2: Make sure they understand how sick they could get if they are taking methadone. 

Step 3: Make sure they understand how sick they could get if they are taking methadone.

Step 4: If they are a new start, you want to see at minimum 6 hours of abstinence and objective signs of withdrawal.  The longer they wait (i.e. the more this goes well.)

     - Use the Clinical Opioid Withdrawal Scale if you are not sure (i.e. COWS) >8.)

     - If you just are not seeing legitimate withdrawal, consider home induction below. 

Step 5: Administer trial dose of Buprenorphine at least 8-16 mg sublingual.

     - Reevaluate severity of withdrawal symptoms after 30 minutes. 

Step 6: If withdrawal symptoms improved/unchanged, proceed with second dose of Buprenorphine.

     - Joint decision making with patient regarding second dose of 8, 16, or 24 mg
     - Heavy users need more, light users need less... (We think no benefit after 32mg total )

Step 4: Prescribe at least one week supply of Suboxone sublingual strips 8 mg BID (14 strips)

     - Sublingual tabs may be substituted for strips per patient preference (avoid tabs if kids in home)


Step 5: Contact the Substance Use Navigator (SUN) 

    - (day hours) Call or text 510-545-2765, or page 510-718-5604

    - (ANY HOUR) route epic chart to "AHS Bridge", or email SUN@alamedahealthsystem.org, or Epic message Kelvin Sen, Andrew Herring, Erik Anderson.  Include best contact number of patient please.


If you think they might fall through the cracks, just HAVE THEM COME BACK to the ED during next day business hours.

Step 6: Provide Naloxone kit and overdose education

Not there yet...Home Start

 *To be used for patients who are not actively withdrawing in the ED (recent opioid use). 


Step 1: Place a 20mcg patch Butrans Patch for indication of PAIN



Step 2: Contact the Substance Use Navigator (SUN

    - SUN will problem solve, motivate, and arrange follow up. 


Step 3: Prescribe at least one week supply of Suboxone sublingual strips 8 mg BID (14 strips)

Step 4: Explain home starts protocol to patient as follows:

1,2,3....Wait, withdrawals, dose 

  1. Wait ( 12 hours)

  2. Make sure you feel really bad from withdrawals.

  3.  Take 8mg tablet or strip UNDER YOUR TONGUE.
    If you don’t feel better in an hour take another 8mg tablet or strip.

    - You shouldn’t don’t need more than 4 strips (32 mg) in a single day.

     - Next Day, Begin Suboxone 8 mg sublingual twice daily dosing starting next morning/evening 

     - Follow up in Bridge Clinic as scheduled. 

     - Contact SUN or return to ED for questions, concerns, or precipitated withdrawal.


Step 5: Provide Naloxone kit and overdose education


Print out Home 

start guide