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FPIN's Clinical Inquiries
From the Family Practice Inquiries Network

Sublingual Buprenorphine for Opioid Use Disorder Treatment

Brendan Jackson-Fowl, DO
Agnes Kim, MD
Vivian Cheng, PharmD

American Family Physician. 2026;113(1):85-86.

Author disclosure: No relevant financial relationships.

This clinical content conforms to AAFP criteria for CME.

CLINICAL QUESTION

What is the optimal dose of sublingual buprenorphine for maintenance treatment of opioid use disorder (OUD)?

EVIDENCE-BASED ANSWER

Physicians managing patients with OUD should consider prescribing maintenance dosages of buprenorphine 24 to 40 mg/day. (Strength of Recommendation [SOR]: B, cohort studies.) In international trials, use of higher dosages (8 mg/day) of buprenorphine results in higher rates of treatment retention at 12 months than lower dosages (3 mg/day, 1 mg/day). (SOR: A, meta-analysis of randomized controlled trials [RCTs].) In US trials, for 12-month treatment retention, dosages of 24 to 40 mg/day are superior to 16 mg/day (number needed to treat [NNT] = 17–31). (SOR: B, cohort studies.) Dosages of 32 to 40 mg/day are superior to 24 mg/day for treatment retention. (SOR: B: cohort study.)

Dosages of buprenorphine greater than 16 mg/day are associated with lower overdose-related mortality (NNT = 167) and all-cause mortality (NNT = 334). Dosages of 24 mg/day or greater are associated with longer times to emergency department and hospital admission than lower dosages. (SOR: B, cohort studies.)

EVIDENCE SUMMARY

A 2022 systematic review of nine RCTs (N = 2,141) evaluated factors associated with buprenorphine treatment retention in adults who had OUD. Three RCTs evaluated daily dosing (1, 3, and 8 mg in all three studies) and study retention at 6 to 12 months (n = 1,056) at a single center in Iran. Most of the studies involved adults (mean ages = 31 to 37 years), and the majority of participants were male.1

In two RCTs, retention rates were higher in the 8-mg groups than the 1-mg groups (80% vs 34%; P = .00001 in the first trial, and 63% vs 17%; P = .00002 in the second trial) and 3-mg groups (80% vs 64%; P = .001 in the first trial and 63% vs 39%; P = .027 in the second trial). In the third RCT, the likelihood of treatment failure was higher with a 1-mg vs 8-mg dose (odds ratio [OR] = 5.0; 95% CI, 3.46–7.24) and a 3-mg vs 8-mg dose (OR = 2.09; 95% CI, 1.4–3.11). Limitations included the same author for three of the RCTs, poor patient retention across all three RCTs (40%–60%), and the low doses of buprenorphine used.1

A 2025 US retrospective cohort study of multi-payer prescription claims (N = 498,879) compared daily buprenorphine-naloxone dosages up to 40 mg vs 16 mg and OUD treatment retention (defined as having an active prescription) over 18 months. Patients (mean age = 38 years; 42% female; 67% commercially insured) were prescribed buprenorphine in daily dosages of 16 mg (46%), 20 mg (5%), 24 mg (13%), 28 mg (1%), 32 mg (2%), 36 mg (0.2%), or 40 mg (0.4%). At 12 months, patients on doses 24 mg or greater had a higher likelihood of treatment retention compared with those on 16 mg (24 mg: adjusted OR = 1.21; 95% CI, 1.19–1.24; NNT = 31; 32 mg: adjusted OR = 1.31; 95% CI, 1.25–1.37; NNT = 18; and 40 mg: adjusted OR = 1.32; 95% CI, 1.21–1.44; NNT = 23). Patients taking doses of 24 mg or greater had better treatment retention at all other time points between 1 and 18 months.2

BRENDAN JACKSON-FOWL, DO; AGNES KIM, MD; and VIVIAN CHENG, PharmD, Valley Family Medicine, Renton, Washington

Address correspondence to Vivian Cheng, PharmD, at vivian_cheng@valleymed.org.

Author disclosure: No relevant financial relationships.

  1. 1.Kennedy AJ, Wessel CB, Levine R, et al. Factors associated with long-term retention in buprenorphine-based addiction treatment programs: a systematic review. J Gen Intern Med. 2022;37(2):332-340.
  2. 2.Stringfellow EJ, Dong H, Khatami SN, et al. The association between buprenorphine doses above 16 milligrams and treatment retention in a multi-payer national sample in the United States, 2014 to 2021. Addiction. 2025;120(6):1198-1206.
  3. 3.Chambers LC, Hallowell BD, Zullo AR, et al. Buprenorphine dose and time to discontinuation among patients with opioid use disorder in the era of fentanyl. JAMA Netw Open. 2023;6(9):e2334540.
  4. 4.Lei F, Lofwall MR, McAninch J, et al. Higher first 30-day dose of buprenorphine for opioid use disorder treatment is associated with decreased mortality. J Addict Med. 2024;18(3):319-326.
  5. 5.Axeen S, Pacula RL, Merlin JS, et al. Association of daily doses of buprenorphine with urgent health care utilization. JAMA Netw Open. 2024;7(9):e2435478.
  6. 6.Weimer MB, Herring AA, Kawasaki SS, et al. ASAM clinical considerations: buprenorphine treatment of opioid use disorder for individuals using high-potency synthetic opioids. J Addict Med. 2023;17(6):632-639.

Clinical Inquiries provides answers to questions submitted by practicing family physicians to the Family Physicians Inquiries Network (FPIN). Members of the network select questions based on their relevance to family medicine. Answers are drawn from an approved set of evidence-based resources and undergo peer review. The strength of recommendations and the level of evidence for individual studies are rated using criteria developed by the Evidence-Based Medicine Working Group (https://www.cebm.net).

The complete database of evidence-based questions and answers is copyrighted by FPIN. If interested in submitting questions or writing answers for this series, go to https://www.fpin.org or email questions@fpin.org.

Copyright © Family Physicians Inquiries Network. Used with permission.

This series is coordinated by John E. Delzell Jr., MD, MSPH, associate medical editor.

A collection of FPIN’s Clinical Inquiries published in AFP is available at https://www.aafp.org/afp/fpin.

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