- Type: Opioid- maintenance therapy in opioid use disorder, rapid detox
- Dosage Forms: injectable solution, sublingual tablet
- Dosage Strengths: injectable solution: 0.3 mg/mL; sublingual tablet: 2, 8mg
- Routes of Administration: Buccal, sublingual, intradermal, transdermal, IV, IM
- Common Trade Names: Suboxone (buprenorphine + naloxone), Buprex
Highly variable, dependent on individual
- For Clinical Opioid Withdrawal Scale (COWS) >=8: 4mg, observe 45min, redose if COWS remains >=8. Then discharge home with 16 mg a day for 2 days if you are able to prescribe, other wise consider return to the ER on day 2 and 3 for a 16 mg dose per day.
- For Clinical Opioid Withdrawal Scale (COWS) 0-7: Do not dose in the ER. If you can prescribe consider unobserved home induction instructions available on paper  and app .
- If sublingual tablets/films unavailable then intravenous/intramuscular formulation (dose 0.3-0.9 mg every 6-12 hours) has been used for opioid withdrawal in the ED and hospitalized patients.
- Suboxone initial induction dose: 2mg/0.5mg or 4mg/1mg, titrate up by 2-4mg q2h based on withdrawal symptoms up to 8mg/1mg
- Pregnancy Rating: C
- Lactation risk: Infant risk has been demonstrated
- Hepatic dosing: reduce dose or do not use in moderate - severe impairment
- Renal dosing:
- Allergy to class/drug
- SBO, paralytic ileus
- Acute/severe asthma (if unmonitored), respiratory depression
- Hypotension, prolonged QT, MI
- Respiratory depression
- Sedation, coma
- Drug dependence or withdrawal
- Constipation, nausea, diarrhea, xerostomia
- Dizziness, headache, somnolence
- URI symptoms
- Half-life: 24-48 hours
- Metabolism: Extensive hepatic, CYP3A4 substrate
- Excretion: Mostly fecal, some renal
Mechanism of Action
- Mixed opiate agonist-antagonist, partial mu-opioid agonist, kappa-opioid antagonist
- Combined with naloxone to deter abuse. The naloxone has no effect when used as intended under the tongue. The naloxone is only active when abused by crushing/injection. Buprenorphine and buprenorphine/naloxone are interchangeable. Buprenorphine/naloxone is now generic in the USA.
- No DATA 2000 Waiver (aka X Waiver) required to administer within the ED for up to 72h (e.g. patient can come back to ED for daily dose for 3 days)
- A Guide for Patients Beginning Buprenorphine Treatment at Home https://medicine.yale.edu/edbup/quickstart/Home_Buprenorphine_Initiation_338574_42801_v1.pdf
- A Patient’s Guide to Starting Buprenorphine at Home from ASAM https://www.asam.org/docs/default-source/education-docs/unobserved-home-induction-patient-guide.pdf
- Buprenorphine Home Induction Apple App Store https://apps.apple.com/us/app/buprenorphine-home-induction/id1449302173
- Starting Buprenorphine from Google Play Store https://play.google.com/store/apps/details?id=com.amstonstudio.bup&hl=en_US&gl=US
- Berg ML, et. al. Evaluation of the use of buprenorphine for opioid withdrawal in an emergency department. Drug Alcohol Depend. 2007 Jan 12;86(2-3):239-44. https://doi.org/10.1016/j.drugalcdep.2006.06.014. Epub 2006 Aug 22. PMID: 16930865.
- Welsh CJ, Suman M, Cohen A, et al. The use of intravenous buprenorphine for the treatment of opioid withdrawal in medically ill hospitalized patients. Am J Addict. 2002;11(2):135-40 https://doi.org/10.1080/105500490290087901
- Suboxone prescribing pamphlet https://www.suboxone.com/hcp/induction-phase