From the Guidelines
Suboxone (buprenorphine) can depress respiratory status, but the risk is rare and typically only occurs when combined with other sedatives or hypnotics, such as benzodiazepines. The potential for respiratory depression is a known adverse effect of buprenorphine, as noted in a 2020 clinical policy published in the Annals of Emergency Medicine 1. However, it's essential to understand that buprenorphine has a ceiling effect on respiratory depression due to its partial agonist activity, making it safer than full opioid agonists.
Key points to consider:
- Buprenorphine's affinity for the μ-receptor and partial agonist activity results in a ceiling on respiratory depression, reducing the risk of overdose compared to full opioid agonists 1.
- The risk of respiratory depression is higher when buprenorphine is combined with other central nervous system depressants, such as benzodiazepines or alcohol.
- Patients should be monitored for signs of respiratory depression, including slow or shallow breathing, confusion, or extreme drowsiness, especially during the first 3-7 days of treatment.
- The ceiling effect of buprenorphine on respiratory depression is a critical factor in its relative safety for opioid use disorder treatment, as noted in the 2020 clinical policy 1.
Overall, while Suboxone can depress respiratory status, the risk is relatively low, and the benefits of treatment often outweigh the potential harms, especially when used appropriately and under medical supervision.
From the FDA Drug Label
Life-Threatening Respiratory Depression Serious, life-threatening, or fatal respiratory depression has been reported with the use of opioids, even when used as recommended. While serious, life-threatening, or fatal respiratory depression can occur at any time during the use of buprenorphine hydrochloride, the risk is greatest during the initiation of therapy or following a dosage increase. Inform patients of the risk of life-threatening respiratory depression, including information that the risk is greatest when starting buprenorphine hydrochloride or when the dosage is increased, and that it can occur even at recommended dosages
Yes, Suboxone (buprenorphine) can depress respiratory status. The risk of respiratory depression is greatest during the initiation of therapy or following a dosage increase, and it can occur even at recommended dosages 2, 2. Patients with chronic pulmonary disease, elderly, cachectic, or debilitated patients are at increased risk of decreased respiratory drive, including apnea, even at recommended dosages of buprenorphine hydrochloride 2.
From the Research
Respiratory Depression and Suboxone
- Suboxone, which contains buprenorphine, can depress respiratory status, particularly when combined with sedatives such as benzodiazepines 3.
- Buprenorphine is a partial agonist at the mu opioid receptor and has a relatively low maximum effect on respiratory depression, but it can still produce serious respiratory depression 3.
- The risk of respiratory depression is higher when buprenorphine is combined with other substances, such as benzodiazepines, opioids, ethanol, and amphetamines 4.
Reversal of Buprenorphine-Induced Respiratory Depression
- Naloxone can reverse buprenorphine-induced respiratory depression, but the reversal is often short-lived and may require continuous infusion of naloxone 5, 6.
- The effectiveness of naloxone in reversing buprenorphine-induced respiratory depression depends on the dose of buprenorphine and the correct dose window of naloxone 6.
- Increasing doses of naloxone can produce a bell-shaped reversal curve, with maximal reversal at naloxone doses between 2 and 4 mg 5.
Frequency of Respiratory Depression
- Respiratory depression occurred in 11.8% of pediatric single-substance buprenorphine oral exposures, 11.2% of pediatric multiple-substance exposures, 11.3% of adult single-substance exposures, and 11.9% of adult multiple-substance exposures 4.
- The frequency of respiratory depression and other serious outcomes, including deaths, has increased over time, with a 65-fold increase in reported cases between 2003 and 2019 4.