What happens if a patient holds Suboxone (buprenorphine) saliva in the buccal area for 30 minutes?

Effects of Holding Suboxone Saliva in Buccal Area for 30 Minutes

Holding Suboxone (buprenorphine) saliva in the buccal area for 30 minutes can lead to continued drug absorption, potentially increasing the risk of overdose or adverse effects.

Buprenorphine Absorption Mechanism

• Buprenorphine has high affinity but low efficacy at mu-opioid receptors, making it a partial agonist that can block or compete with full opioid agonists 1
• Sublingual absorption of buprenorphine is relatively high (approximately 55%) compared to other opioids like morphine (18%) 2
• Buprenorphine absorption is contact-time dependent, meaning longer exposure to oral mucosa can increase absorption 2

Risks of Extended Buccal Contact

• Prolonged buccal retention of Suboxone saliva may lead to:
  • Increased drug absorption beyond intended dosing 2
  • Potential overdose symptoms including respiratory depression, sleepiness, and confusion 3
  • Risk of serotonin syndrome if patient is on other serotonergic medications (e.g., tricyclic antidepressants) 4

Proper Administration Guidelines

• Buprenorphine sublingual tablets must be administered whole - do not cut, chew, or swallow 3
• Patients should be advised not to eat or drink anything until the tablet is completely dissolved 3
• Tablets should be placed under the tongue until dissolved; swallowing the tablets reduces bioavailability 3
• For doses requiring multiple tablets, patients should either place all tablets at once or two at a time under the tongue 3
• Patients should continue to hold tablets under the tongue until they dissolve 3

Clinical Implications

• Excessive saliva accumulation with buprenorphine can occur and may increase risk of aspiration pneumonia 5
• Patients should follow consistent administration technique to ensure bioavailability remains predictable 3
• Proper administration technique should be demonstrated to patients to avoid misuse 3
• Patients should be monitored for signs of overdose including feeling faint, dizzy, confused, or experiencing slowed breathing 3

Management Recommendations

• If a patient reports holding Suboxone saliva in their mouth for extended periods:
  • Assess for signs of overdose including respiratory depression, excessive sedation, or confusion 3
  • Have naloxone available if signs of overdose are present 1
  • Educate patient on proper administration technique to avoid future incidents 3
  • Consider monitoring the patient for several hours if symptoms of increased drug effect are noted 3

Important Precautions

• Patients should be instructed to spit out saliva after the tablet has completely dissolved rather than holding it in the mouth 3
• Patients on other medications that may interact with buprenorphine (such as benzodiazepines, sedatives, or antidepressants) are at higher risk for adverse effects if additional absorption occurs 3, 4
• Patients with liver impairment may be more susceptible to adverse effects from increased absorption due to decreased drug metabolism 3

Remember that Suboxone contains naloxone specifically to deter misuse, but this deterrent is only effective if the medication is injected, not if it's held in the mouth for extended periods 6.