What sleeping medications are safe to take with Suboxone (buprenorphine/naloxone)?

Safe Sleeping Medications to Take with Suboxone

Low-dose doxepin (3-6mg) is the safest and most appropriate sleeping medication to use with Suboxone (buprenorphine/naloxone) due to its favorable safety profile and minimal risk of respiratory depression. 1

Recommended Medications

When considering sleep medications for patients on Suboxone, safety is paramount due to the potential for respiratory depression when opioids are combined with other central nervous system depressants. Here's a prioritized list of options:

1. First-line option: Low-dose doxepin (3-6mg)

   • Minimal respiratory depression risk
   • Effective for sleep maintenance insomnia
   • Particularly suitable for those with substance use disorders
   • Few anticholinergic effects and minimal next-day impairment 1

2. Second-line option: Ramelteon (8mg)

   • Melatonin receptor agonist with no abuse potential
   • No controlled substance status
   • Effective for sleep onset insomnia
   • No significant respiratory depression 1

Medications to Avoid with Suboxone

Several sleep medications should be strictly avoided when taking Suboxone:

• Benzodiazepines (temazepam, diazepam, etc.): High risk of dangerous respiratory depression when combined with opioids like buprenorphine; risk of dependency and cognitive impairment 2, 1

• Benzodiazepine receptor agonists (zolpidem, zaleplon, eszopiclone): Though safer than traditional benzodiazepines, they still carry risk of respiratory depression when combined with opioids 2, 3

• Trazodone: Limited efficacy for insomnia and adverse effect profile outweighs benefits when combined with Suboxone 2

• Antihistamines: Antimuscarinic effects and rapid development of tolerance make these poor choices 1

• Antipsychotics (quetiapine): Significant safety concerns and strongly advised against for insomnia treatment 1

Non-Pharmacological Approaches

Before considering any medication, non-pharmacological approaches should be attempted:

• Cognitive Behavioral Therapy for Insomnia (CBT-I): First-line treatment for chronic insomnia with superior efficacy and safety compared to medications 1

• Sleep hygiene education: Regular sleep schedule, limiting screen time before bed, comfortable sleep environment

• Stimulus control techniques: Using the bed only for sleep and sex, leaving the bed if unable to sleep

Monitoring and Follow-up

When starting any sleep medication while on Suboxone:

• Begin with the lowest effective dose
• Monitor closely for excessive sedation, respiratory depression, and other adverse effects
• Schedule follow-up within 2-4 weeks to assess effectiveness and side effects 1

Clinical Pitfalls to Avoid

• Never combine Suboxone with benzodiazepines unless absolutely necessary and with extreme caution - this combination has resulted in numerous fatalities due to respiratory depression
• Avoid assuming that "Z-drugs" (zolpidem, zaleplon, eszopiclone) are completely safe with Suboxone - while they have a better safety profile than benzodiazepines, they still pose risks when combined with opioids
• Don't overlook the importance of addressing underlying causes of insomnia in patients on Suboxone, as sleep disturbances are common during opioid maintenance therapy

Remember that patients on Suboxone often have complex medical and psychiatric histories that may affect sleep medication choices. The safest approach is to start with non-pharmacological interventions, followed by low-dose doxepin if medication is necessary.