 Important Buprenorphine Information
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Buprenorphine is a partial opioid agonist. It can cause a diminished response to opioid pain medications.
This patient is taking a combination drug of buprenorphine, a partial opiate agonist, and naloxone, an opioid antagonist (naloxone is only clinically active when abused parenterally). Patients taking buprenorphine may have a diminished response to opiate medications (including those for the management of cough or pain).
Opiate-containing preparations should be avoided when non-opiate therapy is available as an alternative. In an emergency situation requiring pain relief in patients taking buprenorphine, a suggested plan of management is regional anesthesia, conscious sedation with a benzodiazepine, use of non-opioid analgesics or general anesthesia. In a situation requiring opiate analgesia, the dose of opiate required may be greater than usual. A rapidly acting opiate analgesic, which minimizes the duration of respiratory depression, should be used. The dose of opioid medication should be titrated against the patient's analgesic and physiological response, with close monitoring by trained staff.
Overdose with buprenorphine alone is uncommon. In a situation that a patient taking buprenorphine has overdosed and is unconscious, the primary management should be the re-establishment of adequate ventilation with mechanical assistance of respiration, if required. Overdose in combination with other CNS depressants should be considered because of the increased potential for life-threatening events. Naloxone may not be effective in reversing any respiratory depression produced by buprenorphine. High doses of naloxone hydrochloride, 10-35 mg/70 kg, may be of limited value in the management of buprenorphine overdose. Doxapram (a respiratory stimulant) has also been used. |
Important documentation and resources:
Suboxone/Subutex (buprenorphine-naloxone / buprenorphine) PI (FDA Label):
http://www.fda.gov/cder/foi/label/2002/20732lbl.pdf
Clinical Guidelines for the Use of Buprenorphine in the Treatment of Opioid Addiction SAMHSA- TIP-40:
http://www.naabt.org/links/TIP_40_PDF.pdf
Physician Clinical Support System (PCSS): http://www.PCSSmentor.org
The SAMHSA-funded PCSS service is available, at no cost, to interested physicians and staff, to assist in implementing office-based treatment of opioid dependence with buprenorphine: 1-877-630-8812 email: PCSSproject@asam.org
The buprenorphine MOA illustration, for a quick understanding: http://www.naabt.org/collateral/How_Bupe_Works.pdf
List of certified physicians near you (some may be available to give advice): http://naabt.org/local/
How do I manage acute pain in a patient receiving buprenorphine/naloxone (bup/nx) for the treatment of opioid dependence?
PCSS Clinical Guidelines – Treating acute pain in buprenorphine maintained patients: http://www.pcssmentor.org/pcss/documents2/PCSS_AcutePain.pdf
Article: Annals of Internal Medicine, Acute Pain Management for Patients Receiving Maintenance Methadone or Buprenorphine Therapy: http://www.annals.org/cgi/reprint/144/2/127.pdf
Can a physician dispense buprenorphine for opioid dependence without a waiver?
Yes. Dispensing of buprenorphine in emergencies by non-DATA-2000 certified physicians (the 72 hour rule, DEA-1306.07): http://www.naabt.org/documents/three-day-rule.pdf
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