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

Treatment of Suboxone (Buprenorphine) Overdose

In case of Suboxone (buprenorphine) overdose, the primary treatment is administering naloxone, an opioid antagonist, to reverse respiratory depression while establishing airway protection and providing ventilatory support as needed. 1

Clinical Presentation of Buprenorphine Overdose

• Buprenorphine overdose typically presents with respiratory depression, somnolence progressing to stupor or coma, skeletal muscle flaccidity, cold and clammy skin, and constricted pupils 1
• In severe cases, pulmonary edema, bradycardia, hypotension, hypoglycemia, partial or complete airway obstruction, atypical snoring, and death may occur 1
• Unlike typical opioid overdose, marked mydriasis (dilated pupils) rather than miosis (constricted pupils) may be seen with hypoxia in buprenorphine overdose situations 1

Treatment Algorithm

Step 1: Establish Airway and Breathing

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

Step 2: Administer Naloxone

• Administer naloxone 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: Provide Supportive Care

• Employ supportive measures including oxygen and vasopressors in the management of circulatory shock and pulmonary edema as indicated 1
• Cardiac arrest or arrhythmias will require advanced life-support measures 1
• Monitor vital signs, especially respiratory rate and oxygen saturation 1

Step 4: Special Considerations for Physically-Dependent Patients

• In patients physically dependent on opioids, administer naloxone with care and by titration with smaller than usual doses to avoid precipitating severe withdrawal 1
• The severity of withdrawal symptoms will depend on the degree of physical dependence and the dose of antagonist administered 1

Important Clinical Considerations

• Buprenorphine is a partial mu-opioid receptor agonist with a high binding affinity, making overdose treatment potentially more challenging than with full agonists 2
• Buprenorphine has safety advantages over full mu agonists because respiratory depression tends to plateau as dose increases, but overdose is still possible, especially when combined with other central nervous system depressants 2
• The naloxone component in Suboxone is poorly absorbed via the sublingual route and is present only to prevent misuse of the medication by crushing and injecting 3
• Patients should be monitored for at least 24-48 hours due to buprenorphine's long duration of action 1

Post-Overdose Care

• Consider initiation of medication-assisted treatment (MAT) for patients with opioid use disorder following stabilization 4, 5
• Naloxone prescriptions should be provided upon discharge to prevent future overdose-related mortality 5
• Linkage to treatment and harm reduction services have the potential to prevent future overdose for those at risk 6

Common Pitfalls and Caveats

• Underestimating the duration of monitoring needed - buprenorphine's effects last 36-48 hours while naloxone's effects last only 1-3 hours 1
• Failing to recognize that standard doses of naloxone may be insufficient to reverse buprenorphine-induced respiratory depression due to buprenorphine's high receptor affinity 1
• Not providing post-overdose resources - studies show that naloxone and buprenorphine are only prescribed after 1 in 13 and 1 in 12 ED visits for opioid overdose, respectively, missing critical opportunities to prevent future overdose-related mortality 5