Can Suboxone (buprenorphine) and oxycodone be used concurrently?

Suboxone and Oxycodone: Concurrent Use Considerations

Concurrent use of Suboxone (buprenorphine/naloxone) and oxycodone is contraindicated due to the antagonistic pharmacological properties of buprenorphine, which can precipitate withdrawal symptoms and reduce the analgesic effect of oxycodone. 1

Pharmacological Interaction

• Buprenorphine is a partial mu-opioid receptor agonist with high receptor affinity but low efficacy, which can displace full agonists like oxycodone from opioid receptors 2
• The FDA label for oxycodone specifically warns against concomitant use with mixed agonist/antagonist opioid analgesics (including buprenorphine), as this may reduce the analgesic effect of oxycodone and/or precipitate withdrawal symptoms 1
• Buprenorphine's high binding affinity for mu-opioid receptors can block the effects of full opioid agonists like oxycodone, rendering them ineffective for pain management 2

Clinical Implications

• When a patient on Suboxone requires acute pain management:

  • Buprenorphine should be discontinued 24-36 hours before initiating oxycodone to allow the receptors to become available for full agonist binding 3
  • For patients with opioid use disorder on maintenance therapy, discontinuing Suboxone carries significant risk of relapse 3
  • Higher doses of full opioid agonists may be required to overcome buprenorphine's blockade effect, increasing the risk of respiratory depression when buprenorphine levels decline 1

• When a patient on oxycodone needs to transition to Suboxone:

  • Oxycodone should be discontinued and the patient should be in mild to moderate withdrawal before initiating Suboxone 3
  • Initiating Suboxone too early can precipitate acute withdrawal symptoms 3
  • Short-acting opioids like oxycodone should be discontinued at least 12-24 hours before Suboxone induction 3

Special Considerations

• For perioperative management:

  • The Society for Perioperative Assessment and Quality Improvement (SPAQI) recommends individualizing the approach based on:
    • The prescribed daily dose of buprenorphine
    • Indication for buprenorphine treatment (pain vs. dependency)
    • Risk of relapse
    • Expected level of post-surgical pain 3
  • For patients with opioid use disorder, maintaining buprenorphine therapy and using multimodal analgesia is increasingly preferred over discontinuation 3

• For pregnant patients:

  • Buprenorphine is preferred over full opioid agonists for treating opioid use disorder during pregnancy 3
  • Concurrent use of benzodiazepines or other CNS depressants with either medication increases risk of respiratory depression 3

Safety Concerns with Concurrent Use

• Potential adverse effects of concurrent use include:

  • Precipitated withdrawal symptoms 1, 2
  • Reduced analgesic efficacy of oxycodone 1
  • Unpredictable respiratory depression risk 1
  • Increased risk of overdose when attempting to overcome buprenorphine's blocking effects with higher doses of oxycodone 3

• The CDC Guideline for Prescribing Opioids emphasizes avoiding concurrent use of opioid agonists with partial agonists/antagonists due to these risks 3

Alternative Approaches

• For patients with opioid use disorder requiring pain management:

  • Continue buprenorphine and add non-opioid analgesics (NSAIDs, acetaminophen) 3
  • Consider regional anesthesia techniques when appropriate 3
  • If opioids are necessary for acute severe pain, higher doses of full agonists may be required under close monitoring 3

• For patients transitioning between medications:

  • A carefully managed, medically supervised transition period is essential 3
  • Withdrawal symptoms should be monitored using validated opioid withdrawal scales 3

In summary, Suboxone and oxycodone should not be used concurrently due to pharmacological incompatibility, risk of precipitated withdrawal, and reduced analgesic efficacy. Any transition between these medications requires careful clinical management and appropriate timing to minimize adverse effects.