What are the treatment steps for a Suboxone (buprenorphine) overdose?

Treatment of Suboxone (Buprenorphine/Naloxone) Overdose

In case of Suboxone overdose, treatment priorities are reestablishing a patent airway, instituting assisted ventilation if needed, and administering naloxone as a specific antidote to reverse respiratory depression. 1

Clinical Presentation of Suboxone Overdose

• Suboxone (buprenorphine/naloxone) overdose manifests primarily as respiratory depression, which can be life-threatening 1
• Other symptoms include somnolence progressing to stupor or coma, skeletal muscle flaccidity, cold/clammy skin, and constricted pupils 1
• In severe cases, pulmonary edema, bradycardia, hypotension, hypoglycemia, and airway obstruction may occur 1
• Unlike typical opioid overdoses, marked mydriasis (dilated pupils) rather than miosis (constricted pupils) may be seen with hypoxia in overdose situations 1

Emergency Management Algorithm

Step 1: Airway and Breathing Support

• Immediately establish a patent and protected airway 1
• Institute assisted or controlled ventilation if respiratory depression is present 1
• Administer oxygen to maintain adequate oxygenation 1

Step 2: Pharmacological Intervention

• Administer naloxone (Narcan) for clinically significant respiratory or circulatory depression 1
• Important consideration: Buprenorphine has a longer duration of action (36-48 hours) than naloxone (1-3 hours), requiring careful monitoring and potentially repeated naloxone dosing 1
• Continue monitoring the patient until spontaneous respiration is reliably reestablished 1
• If response to naloxone is suboptimal or brief, administer additional doses as needed 1

Step 3: Supportive Care

• Employ supportive measures including oxygen and vasopressors for managing circulatory shock and pulmonary edema 1
• Implement advanced life-support measures for cardiac arrest or arrhythmias 1
• Monitor for hypoglycemia and treat if present 1

Special Considerations

• For patients physically dependent on opioids: Naloxone administration may precipitate acute withdrawal syndrome 1
• In physically dependent patients, initiate antagonist treatment with care, using smaller than usual doses of naloxone and titrating carefully 1
• Be aware of potential serotonin syndrome in patients taking serotonergic medications (such as tricyclic antidepressants) along with buprenorphine 2
• Cyproheptadine, a serotonin receptor antagonist, may be beneficial if serotonin syndrome develops 2

Post-Overdose Care

• Patients who survive opioid overdose should be considered high risk, with the first month (especially first 2 days) being the highest-risk period for mortality 3
• Consider offering buprenorphine treatment, counseling, and referral to treatment before ED discharge 3
• Long-term follow-up is essential as studies show 5.5% of patients treated for opioid overdose die within 1 year 3

Prevention of Future Overdoses

• Medication-assisted treatment (MAT) using buprenorphine has shown approximately 80% reduction in illicit opioid use 4
• Ensure access to naloxone for patients at risk of overdose and train family members in its use 4
• Consider referral to specialized treatment programs for ongoing substance use disorder management 4

Remember that buprenorphine has a ceiling effect on respiratory depression due to its partial agonist properties, making overdoses less common than with full opioid agonists, but they can still be life-threatening and require prompt intervention.