Can an opioid be given with buprenorphine (Suboxone)?

Can Opioids Be Given With Buprenorphine?

Yes, opioids can be given with buprenorphine, but higher doses of full opioid agonists are typically required to compete with buprenorphine's high affinity for the μ-receptor, and close monitoring for respiratory depression is essential. 1

Clinical Approach to Co-Administration

Option 1: Continue Buprenorphine and Add Full Agonist Opioids (Preferred for Most Cases)

• Continue the patient's maintenance buprenorphine dose and titrate short-acting full opioid agonists (morphine, hydromorphone, oxycodone) to effect. 1
• Higher doses of full agonist opioids will be required compared to opioid-naive patients because buprenorphine's high μ-receptor affinity creates competitive binding. 1
• This approach avoids withdrawal and maintains addiction treatment continuity. 2
• Critical monitoring requirement: Naloxone must be immediately available, and level of consciousness plus respiratory rate should be frequently monitored due to variable rates of buprenorphine dissociation from the μ-receptor. 1

Option 2: Divide Buprenorphine Dosing for Analgesia

• Split the daily buprenorphine dose into every 6-8 hour administration to leverage its analgesic properties (e.g., 32 mg daily becomes 8 mg every 6 hours). 1
• Additional full opioid agonists (morphine, hydromorphone) may still be required, as divided buprenorphine dosing alone may not provide adequate analgesia in opioid-tolerant patients. 1

Option 3: Discontinue Buprenorphine and Use Full Agonists (For Severe Acute Pain)

• Stop buprenorphine and treat with scheduled full opioid agonist analgesics (sustained-release and immediate-release morphine) titrated to prevent withdrawal first, then achieve analgesia. 1
• When acute pain resolves, discontinue the full agonist and restart buprenorphine using a formal induction protocol. 1
• Critical caveat: The patient must be in mild opioid withdrawal before restarting buprenorphine to avoid precipitating severe withdrawal. 1

Option 4: Convert to Methadone (Inpatient Setting Only)

• Convert buprenorphine to methadone 30-40 mg daily to prevent withdrawal while allowing full agonist opioids to work as expected. 1, 3
• Methadone binds less tightly to the μ-receptor than buprenorphine, permitting dose-dependent analgesia from additional opioids. 1
• Increase methadone in 5-10 mg increments if withdrawal persists. 1
• Upon pain resolution, discontinue methadone and full agonists, then restart buprenorphine using an induction protocol. 1

Critical Safety Considerations

Respiratory Depression Risk

• Respiratory depression from buprenorphine alone is rare due to its ceiling effect, but this ceiling is lost when combined with benzodiazepines or other CNS depressants. 1, 4
• The FDA label explicitly warns that concomitant use of benzodiazepines or CNS depressants with buprenorphine increases risk of hypotension, respiratory depression, profound sedation, coma, and death. 4
• Reserve concomitant prescribing only when alternative treatment options are inadequate, and limit dosages and durations to the minimum required. 4

Risk of Precipitated Withdrawal

• Never give buprenorphine to a patient currently using full agonist opioids who is not yet in active withdrawal. 1
• Buprenorphine's high binding affinity and partial agonist properties will displace full agonists from the μ-receptor, precipitating severe withdrawal. 1
• Confirm active opioid withdrawal by history, physical examination, and objective tools like the Clinical Opiate Withdrawal Scale before administering buprenorphine. 1
• Particular caution is required when transitioning from methadone to buprenorphine due to risk of severe and prolonged precipitated withdrawal. 1

Medications to Absolutely Avoid

• Mixed agonist-antagonist opioids (pentazocine, nalbuphine, butorphanol) must be avoided as they will displace buprenorphine from the μ-receptor and precipitate acute opioid withdrawal. 1
• Do not combine buprenorphine with opioid antagonists (naloxone, naltrexone) as this precipitates withdrawal. 2

Increased Sensitivity Upon Buprenorphine Discontinuation

• If buprenorphine is abruptly discontinued after adding full agonist opioids, the patient may experience increased sensitivity to the full agonist with respect to sedation and respiratory depression. 1
• This occurs because buprenorphine's protective ceiling effect is removed while full agonist levels remain elevated. 1

Perioperative Context

• Continue buprenorphine perioperatively rather than holding it, as discontinuation risks withdrawal and relapse. 1, 2
• The decision should reflect the prescribed daily dose, indication for treatment (pain vs. opioid use disorder), risk of relapse, and expected level of postsurgical pain. 1, 2
• Individualize the approach based on these factors, but default to continuation when possible. 1

Practical Dosing Considerations

• Combination products containing fixed-dose acetaminophen with opioids (Percocet, Vicodin) should be limited to avoid acetaminophen-induced hepatotoxicity when high opioid doses are required. 1
• Prescribe acetaminophen and opioids separately at appropriate doses to achieve analgesia while avoiding hepatic damage. 1