Getting Started on MAT: A Cautionary Tale

A few weeks ago I took a patient to begin medication-assisted treatment (MAT) for opioid use disorder (OUD). After weeks of thorough discussion and consideration, the patient decided to try Suboxone as his medication for MAT. When the day came, I trusted that the clinic would handle things the right way, so I did not accompany my patient into the exam room as I usually would have. Turns out, the clinic absolutely DID NOT handle things right and things went terribly wrong.

The use of medication-assisted treatment has been shown to lower the risk of fatal overdoses by approximately 50%.

In order to ensure that I approached this opportunity for education from a clinical focus instead of an emotional one, I waited several weeks before writing this explanation. With that in mind, please allow me – a certified MAT Specialist and MATS trainer – to shed some light on what went wrong that day and why. To make it as easy as possible to understand, I will start with some background on the medication and the recommended process for its use.

What is Suboxone?

Suboxone is a brand name prescription used for MAT. Specifically, it is a combination of the medications Buprenorphine and Naloxone at a 4:1 ratio.

Buprenorphine hydrochloride is a synthetic opioid developed in the late 1960s and is used to treat pain and opioid use disorder (OUD).

Naloxone hydrochloride (best known by the brand name Narcan) is the drug used to reverse opioid overdose. It is an opioid antagonist that works to block neuroreceptors from recognizing the presence of opioids in the body.

Suboxone binds to the same receptors in the brain – known as mu (μ) – as other opiates (such as heroin, morphine, and oxycodone), blunting the effect of the other opioids. It prevents cravings, affording many people with OUD the opportunity to return to a more stable life.

Getting Started with Suboxone

Not only does a person need to be mentally prepared to begin treatment, but it is important from a standpoint to start Suboxone treatment at the right time. The risk involved with starting Suboxone too soon is that buprenorphine has a very high affinity for the mu receptor mentioned above, and will displace any other opioid on the receptor, thereby causing precipitated opioid withdrawal.

SAMHSA provides a Buprenorphine Quick Start Guide that covers the basic recommended process for assessing a patient and prescribing MAT, along with important considerations related to initial Suboxone induction.


A thorough assessment should be performed, including:

  • Patient History
    • Medical History
    • Psychiatric History
    • Substance Use History
  • Clinical Opiate Withdrawal Scale (COWS) Assessment


The patient should be informed of how the induction process works, along with the potential risks:

  • The risk of using opioids or other substances while taking Suboxone
  • The risk of relapse and overdose if medication is discontinued
  • The risk of precipitated withdrawal


  1. Begin induction when at least 12 hours have passed since the patient’s last use and they have a current COWS score of 12 or higher.
  2. Instruct the patient how to take the medication: under the tongue, and swallow when fully dissolved.
  3. Administer the first dose of 2/.5-4/1 mg under observation in an office or inpatient setting.
  4. Keep the patient in the office for at least an hour to determine the effect of the first dose, and then document the effect of the first doses in the medical record.
  5. Depending on the amount and type of opioid use, the first day’s dose may range from 2 to 16 mgs.
  6. If withdrawal occurs after the patient leaves the office, request that the patient return for withdrawal assessment. This will be time-consuming, discouraging and not likely to happen. Avoid this complication by taking the time to assure moderate withdrawal discomfort prior to the first dose.

Precipitated Withdrawal

A precipitated withdrawal is one that is caused by a medication rather than by abstaining from opioid use. To avoid precipitated withdrawal, it is important to ensure that the patient is experiencing adequate withdrawal before beginning the induction. As a general rule, that means a COWS score of 12 of higher. Inducing a Fentanyl user may require a higher COWS score and lower initial dosing, starting Suboxone at a lower dose (2.0mg/0.5 mg), and reassessing more frequently.

What Went Wrong

Now that I’ve covered the basic accepted guidelines for Suboxone induction, let’s take a look at how this clinic failed my patient.

  1. There was no COWS assessment performed.
    As mentioned previously, the COWS assessment is an important tool that makes it possible to gauge the patient’s current level of withdrawal from opioids. Without the insight it provides, it is difficult to accurately assess where the patient is in their withdrawal process.
  2. The patient was not even asked by the clinician what opiates he used or how long it had been since he last used.
    In this case, the patient is a fentanyl user, which should mean that the protocol for care followed a slightly different path (higher COWS score before induction, followed by a lower initial dose).
  3. The patient was given an initial Suboxone dose of 8/2mg.
    This is four times the SAMHSA recommendation for inducing fentanyl users.
  4. The patient was released from the clinic immediately after his initial dose, with 10 days of Suboxone and no observation time or instruction on what to do if something went wrong.
    Within 15 minutes of leaving the clinic, he began severe precipitated withdrawals that lasted more than 24 hours.

My client thought he was going to die. I held his hand for nearly six hours while he writhed in pain begging me to help him end it.

None of this should have happened. In response, I plan to a meeting with the Clinical Director at the clinic to ensure that she is fully aware of what took place in this situation. In addition, I will accompany every one of my patients into the exam room as their counselor and advocate, every time.