From the Guidelines
Suboxone (buprenorphine) should not be used in conjunction with heroin due to the high risk of precipitated withdrawal, which can lead to severe and potentially life-threatening symptoms. The mechanism behind this contraindication is rooted in buprenorphine's pharmacology as a partial opioid agonist, which can displace full opioid agonists like heroin from opioid receptors, thereby inducing acute withdrawal 1.
When considering the initiation of buprenorphine in patients who have been using opioids, including heroin, it is crucial to ensure that the patient is in a state of mild to moderate withdrawal. This typically occurs 12-24 hours after the last use of heroin, and the patient's withdrawal severity can be assessed using tools like the Clinical Opiate Withdrawal Scale (COWS) 1.
Key points to consider in the management of patients transitioning from heroin to Suboxone include:
- Buprenorphine may produce acute opioid withdrawal in patients on full mu agonists like heroin 1.
- Patients should discontinue all opioids before initiating buprenorphine, with the timing depending on the duration of action of the opioid used 1.
- The initial dose of buprenorphine should be administered when mild withdrawal is present, starting with 2-4 mg and repeating at 2-hour intervals as needed and tolerated 1.
- The total dose required on the first day can vary, but typically ranges from 4-8 mg, and this dose can be adjusted on subsequent days based on the patient's response 1.
Given the potential for severe withdrawal symptoms and the importance of proper timing for the initiation of buprenorphine, it is essential for patients to be honest about their recent drug use and for healthcare providers to carefully assess the patient's withdrawal status before starting Suboxone 1. This approach minimizes the risk of precipitated withdrawal and ensures a safer transition to medication-assisted treatment.
From the FDA Drug Label
CONTRAINDICATIONS Buprenorphine hydrochloride is contraindicated in patients with: • Significant respiratory depression [see WARNINGS]. • Acute or severe bronchial asthma in an unmonitored setting or in the absence of resuscitative equipment [see WARNINGS]. • Known or suspected gastrointestinal obstruction, including paralytic ileus [see WARNINGS]. • Hypersensitivity to buprenorphine (e.g., anaphylaxis) or any other ingredient in buprenorphine hydrochloride [see WARNINGS].
The use of Suboxone (buprenorphine) with heroin is not directly addressed in the provided drug labels as a contraindication. However, significant respiratory depression is a contraindication for buprenorphine, and combining it with heroin, an opioid that can also cause respiratory depression, may increase this risk.
- Key points:
- Buprenorphine can cause significant respiratory depression.
- Heroin can also cause significant respiratory depression.
- Combining buprenorphine with heroin may increase the risk of respiratory depression. Given the potential for increased risk of respiratory depression, it is reasonable to exercise caution when considering the use of Suboxone with heroin, although the labels do not explicitly state this combination as a contraindication 2.
From the Research
Contraindications of Using Suboxone with Heroin
- The use of Suboxone (buprenorphine) with heroin is not recommended due to the potential risks of adverse interactions and reduced efficacy of Suboxone in treating opioid use disorder 3, 4.
- Buprenorphine, the active ingredient in Suboxone, is a partial agonist of the mu receptor and antagonist of the kappa receptor, which can lead to precipitated withdrawal in individuals physically dependent on heroin 5, 6.
- Studies have shown that buprenorphine can suppress heroin use in heroin-dependent individuals, but the use of Suboxone with heroin can lead to unpredictable outcomes and increased risk of overdose 4, 6.
- The naloxone component of Suboxone can also contribute to adverse effects, such as precipitated withdrawal, in individuals using heroin 3, 7.
Key Considerations
- The use of Suboxone should be carefully monitored and managed by a healthcare professional to minimize the risk of adverse interactions with heroin 4, 7.
- Individuals using Suboxone should be advised to avoid using heroin or other opioids due to the potential risks of adverse interactions and reduced efficacy of Suboxone 3, 6.
- Alternative treatment options, such as methadone or naltrexone, may be considered for individuals with opioid use disorder who are unable to tolerate Suboxone or have a history of heroin use 7.