What is the recommended dosing when using Suboxone (buprenorphine with naloxone) and gabapentin together?

Dosing Recommendations for Suboxone and Gabapentin Combination Therapy

When using Suboxone (buprenorphine with naloxone) and gabapentin together, gabapentin should be started at 100-300 mg nightly and titrated to 900-3600 mg daily in divided doses (2-3 times daily), while buprenorphine dosing should be increased in divided doses (typically 4-16 mg divided into 8-hour doses) for optimal pain management.

Gabapentin Dosing

Standard Dosing

• Initial dose: 100-300 mg at bedtime 1, 2
• Titration: Increase by 50-100% every few days 1
• Target dose: 900-3600 mg daily in divided doses (2-3 times daily) 1, 3
• Slower titration recommended for elderly or medically frail patients 1

Renal Adjustment for Gabapentin

Creatinine Clearance (mL/min)	Total Daily Dose Range (mg/day)	Dose Regimen
≥60	900-3600	300-1200 mg TID
30-59	400-1400	200-700 mg BID
15-29	200-700	200-700 mg QD
≤15	100-300	100-300 mg QD

Buprenorphine/Naloxone (Suboxone) Dosing

• For patients with chronic pain on buprenorphine maintenance:
  • Increase buprenorphine in divided doses as initial step for pain management 1
  • Dosing range: 4-16 mg divided into 8-hour doses has shown benefit in chronic non-cancer pain 1
  • Consider switching from buprenorphine/naloxone to buprenorphine transdermal formulation alone if needed 1

Important Considerations

Safety Concerns

• Respiratory depression risk: The combination of gabapentin and opioids (including buprenorphine) increases the risk of opioid-related death by approximately 49% compared to opioid use alone 4
• Moderate-dose (900-1799 mg/day) and high-dose (≥1800 mg/day) gabapentin with opioids is associated with a nearly 60% increase in the odds of opioid-related death 4

Monitoring Recommendations

• More frequent clinical observation and dose adjustment for patients with renal or hepatic impairment 1
• Monitor for excessive sedation, which may precede respiratory depression 1
• Consider prescribing naloxone for patients receiving ≥50 morphine milligram equivalents or when combining with gabapentin 1

Special Populations

• For patients with renal impairment:
  • Use lower doses of gabapentin with careful titration 2
  • Consider methadone as an alternative to buprenorphine if not contraindicated 1

Management Algorithm

1. Initial Assessment:

   • Evaluate pain type (neuropathic component warrants gabapentin)
   • Assess renal function to determine appropriate gabapentin dosing
   • Review current medications for potential interactions

2. Initiation:

   • Start gabapentin at 100-300 mg nightly
   • For patients already on Suboxone, maintain current dose initially

3. Titration:

   • Increase gabapentin by 50-100% every 3-5 days as tolerated
   • If pain persists despite gabapentin titration, consider increasing buprenorphine dose in divided doses (8-hour intervals)

4. Maintenance:

   • Optimal gabapentin dose: 900-3600 mg/day in divided doses
   • Optimal buprenorphine dose: 4-16 mg/day in divided doses for pain management

5. Monitoring:

   • Assess for sedation, respiratory depression, and other adverse effects
   • More frequent monitoring for patients with renal or hepatic impairment
   • Consider naloxone prescription as a safety measure

If pain remains inadequate despite optimized dosing of both medications, consider transitioning from buprenorphine to methadone maintenance or adding other non-opioid adjuvant therapies appropriate to the pain syndrome 1.