 So when I think of how it can be necessary and the right choice to start somebody on buprenorphine, who is currently opioid naive, I think of a patient that we had in our clinic who is with us actually for a number of years and he did great. When he was with us, he was on a stable dose of buprenorphine and he was working. But at one point, his sibling passed away. His sibling actually died of an overdose. And this caused our patient to really sort of spiral out of control and he really very much destabilized and stopped coming in and had recurrent substance use and he was arrested and incarcerated. And so after a few months of being in jail, he got out and he came back to us and he just really wanted to get back into care and get stable again. This was somebody who wasn't currently using. They had no opioid dependence. He hadn't used in months but we knew that the medicine worked really, really well for him and he had very strong recovery before so we talked it through. It made sense to restart him and so we did. He got stabilized again. It was the right choice. You know, he was back in treatment and we were happy to have him. The goals of treatment with buprenorphine include alleviating symptoms of opioid withdrawal and cravings and the provision of opioid blockade. In addiction treatment programs, healthcare providers often encounter patients who are opioid dependent, meaning that without opioids in their bodies, the patients do not feel normal and may experience painful and uncomfortable withdrawal syndrome. When these patients are treated with buprenorphine, the medication occupies opioid receptor sites, allowing the patient to feel and function normally. What happens when a person has a history of moderate to severe opioid use disorder but is not currently using or physically dependent on opioids? Are these patients candidates for buprenorphine treatment? Many patients who are not opioid dependent or not currently using opioids may benefit from starting or restarting buprenorphine and should be offered this treatment to avoid risk of relapse. Consider the following examples of individuals who are either not currently opioid dependent or not currently using opioids. Yet could benefit from starting or restarting buprenorphine. Example one, an individual with a severe opioid use disorder was being successfully treated with buprenorphine but is forced to stop using the medication while incarcerated. This individual is not currently using opioids and is at high risk of returning to opioid use upon his release from incarceration. Immediately following his release from incarceration this individual has a pronounced risk of fatal overdose. Example two, a person with an opioid use disorder has abstained from opioid use for a year. After the recent death of a friend this individual experiences extreme stress and begins to experience cravings for opioids to help her cope. Having lower tolerance to opioids after her prolonged period of abstinence this person is at increased risk of overdose. Example three, a person recently started using heroin. His use is becoming increasingly dangerous although he is not yet dependent on opioids. However, he is experiencing cravings and losing control of his use which is having negative consequences. He is feeling out of control. All of these cases describe individuals who may benefit from starting or restarting treatment with buprenorphine. Regular opioids such as oxycodone or methadone are full opioid agonists. Buprenorphine, conversely, is a partial opioid agonist meaning that at an appropriate dose there is a sealing effect. Increased amounts of the medication will not result in an increase in effects. This results in an improved safety profile compared to full opioid agonists and lowers the risk of respiratory depression. When buprenorphine is used to treat a patient who is opioid dependent the individual should start to feel and function normally by fulfilling his or her daily opioid requirement. For a person who is not currently dependent on or who is opioid naive buprenorphine can cause euphoria, sedation and increased side effects due to its opioid properties. What are the special considerations for those patients who are not currently opioid dependent? Which of these patients are good candidates to initiate buprenorphine treatment? Healthcare providers need to start with a lower dose of buprenorphine and to slowly titrate the dose upward to manage the symptoms of cravings and to block the effects of other opioids. Patients initiating buprenorphine treatment who are non-opioid dependent will often end up on similar maintenance doses of buprenorphine as their opioid dependent counterparts. While buprenorphine reduces withdrawal signs and symptoms at lower doses higher doses are often necessary to effectively manage opioid cravings and produce blockade. Typical maintenance doses of buprenorphine range from 8 to 24 mg daily. An example titration protocol for starting a patient on buprenorphine who is currently non-opioid dependent would be an induction dose of 2 mg. Buprenorphine would then be titrated upwards every 3 days in 2 mg increments until opioid cravings subside. If at any point during titration a patient experiences signs of overmedication such as sedation or euphoria then the provider should slow down or stop the upward titration and consider a dose decrease. When titrating a patient's dose it is important to remember the goals of treatment to alleviate opioid cravings and withdrawal to cause opioid blockade and to increase the patient's quality of life. Remember, start low, go slow.