Does restarting Suboxone (buprenorphine/naloxone) cause nausea?

Restarting Suboxone and Nausea

Yes, restarting Suboxone (buprenorphine/naloxone) commonly causes nausea as a side effect, which is listed among the common adverse effects in the FDA drug label. 1

Mechanism and Prevalence

• Nausea is one of the most common side effects of buprenorphine/naloxone, occurring during both initial treatment and when restarting therapy 1
• The nausea is related to buprenorphine's opioid agonist properties, which can stimulate the chemoreceptor trigger zone in the brain 2
• Nausea may be more pronounced when restarting Suboxone after a period without it due to changes in opioid tolerance 2

Management of Suboxone-Induced Nausea

Prophylactic Approach

• For patients with a prior history of opioid-induced nausea, prophylactic treatment with antiemetic agents is highly recommended before restarting Suboxone 2
• Effective prophylactic agents include:
  • Phenothiazines (prochlorperazine, thiethylperazine) 2
  • Dopamine receptor antagonists (metoclopramide, haloperidol) 2

Treatment of Established Nausea

• If nausea develops despite prophylaxis, consider the following approach:
  • Start with as-needed antiemetics 2
  • If nausea persists, administer antiemetics around the clock for 1 week and then change to as-needed dosing 2
  • Consider adding serotonin receptor antagonists (ondansetron, granisetron) which have lower rates of CNS effects 2

Combination Therapy for Persistent Nausea

• For persistent nausea, adding therapies with different mechanisms of action may provide synergistic relief 2:
  • Combining metoclopramide with ondansetron 2
  • Adding corticosteroids, which can be quite beneficial for reducing opioid-induced nausea 2
  • Alternative agents like scopolamine, dronabinol, or olanzapine may also be considered 2

Special Considerations

Induction Protocol

• When restarting buprenorphine after using full opioid agonists, patients should be in mild opioid withdrawal before reinitiating buprenorphine to avoid precipitated withdrawal, which can worsen nausea 2
• Proper sublingual administration is crucial - tablets should dissolve completely under the tongue without chewing or swallowing, which can affect absorption and potentially increase side effects 1

Persistent Nausea

• If nausea persists for longer than a week despite treatment:
  • Reassess for other causes of nausea (constipation, CNS pathology) 2
  • Consider opioid rotation to a different formulation or medication 2
  • Dose adjustment may be necessary - starting with lower doses when restarting therapy can reduce nausea 1

Clinical Pitfalls to Avoid

• Don't ignore nausea: Untreated nausea can lead to poor medication adherence and potential relapse 2
• Don't confuse withdrawal symptoms with medication side effects: Nausea can be a symptom of both opioid withdrawal and Suboxone side effects 1
• Don't overlook drug interactions: Certain medications can increase the risk of side effects when combined with buprenorphine 3
• Don't abruptly discontinue antiemetic therapy: Gradually taper antiemetics after nausea resolves 2

Remember that while nausea is common when restarting Suboxone, it is typically manageable with appropriate interventions and often diminishes over time as the body readjusts to the medication 1.