From the Guidelines
Suboxone overdose is a serious medical emergency that requires immediate attention, and naloxone administration is the most effective treatment to reverse the overdose effects, as evidenced by the most recent study in 2024 1. If you suspect someone is overdosing on Suboxone, call 911 immediately. Suboxone contains buprenorphine (a partial opioid agonist) and naloxone (an opioid antagonist), and while it has a "ceiling effect" that makes it safer than full opioid agonists, overdose is still possible, especially in opioid-naive individuals or when combined with other substances. Signs of overdose include:
- Extreme drowsiness
- Pinpoint pupils
- Slowed or stopped breathing
- Blue-tinged lips or fingernails
- Loss of consciousness Naloxone (Narcan) can be administered to reverse the overdose effects, typically 2-4mg intranasally or intramuscularly, which may need to be repeated every 2-3 minutes if breathing doesn't improve, as supported by the 2015 American Heart Association guidelines update for cardiopulmonary resuscitation and emergency cardiovascular care 2. However, because buprenorphine binds strongly to opioid receptors, higher or repeated doses of naloxone may be needed compared to other opioid overdoses. After administering naloxone, place the person in the recovery position (on their side) to prevent choking if they vomit, and stay with them until emergency services arrive. Suboxone overdose risk increases significantly when combined with alcohol, benzodiazepines, or other central nervous system depressants, as these combinations can dangerously suppress breathing. It's essential to note that the goal of naloxone administration is to improve ventilatory effort, not to awaken the patient, as highlighted in the 2024 study 1. Failure to recognize this endpoint may lead to the administration of multiple doses of naloxone, increasing the risk of precipitated opioid withdrawal. Therefore, patients with respiratory compromise from presumed opioid overdose should be treated with supportive care and naloxone, as clinically appropriate, prioritizing the restoration of patent airway and ventilation to prevent respiratory and cardiac arrest.
From the FDA Drug Label
OVERDOSAGE Clinical Presentation Acute overdose with buprenorphine can be manifested by respiratory depression, somnolence progressing to stupor or coma, skeletal muscle flaccidity, cold and clammy skin, constricted pupils, and, in some cases, pulmonary edema, bradycardia, hypotension, hypoglycemia, partial or complete airway obstruction, atypical snoring, and death Treatment of Overdose In the case of overdose, priorities are the reestablishment of a patent and protected airway and institution of assisted or controlled ventilation, if needed Opioid antagonists, such as naloxone, are specific antidotes to respiratory depression resulting from opioid overdose
Suboxone overdose symptoms include respiratory depression, somnolence, stupor, coma, and other severe effects.
- Treatment priorities are to establish a patent airway and provide assisted ventilation if needed.
- Opioid antagonists like naloxone can be used to reverse respiratory depression.
- It is crucial to carefully monitor the patient until spontaneous respiration is reliably reestablished, as the duration of opioid reversal is expected to be less than the duration of action of buprenorphine 3.
From the Research
Suboxone Overdose
- Suboxone, which contains buprenorphine, can cause respiratory depression, particularly when combined with sedatives such as benzodiazepines 4.
- Buprenorphine is relatively resistant to reversal by naloxone, and increasing doses of naloxone can cause a bell-shaped reversal curve of buprenorphine-induced respiratory depression 5.
- High-dose buprenorphine can cause respiratory depression, especially when misused or combined with other substances such as benzodiazepines 6.
- Respiratory depression occurred at a frequency of 11.3% in adult single-substance buprenorphine oral exposures, and 11.9% in adult multiple-substance exposures 7.
- Buprenorphine administration by emergency medical services (EMS) after naloxone overdose reversal is safe and feasible, and partnerships between EMS and outpatient substance use disorder observation units can facilitate buprenorphine initiation 8.
Risk Factors
- Concomitant use of benzodiazepines, opioids, ethanol, and amphetamines with buprenorphine increases the risk of respiratory depression 7.
- High-dose buprenorphine, especially when misused or combined with other substances, can cause severe respiratory depression 6.
- Unsheltered homelessness and barriers to attending opioid treatment programs can increase the risk of overdose and complications 8.
Treatment
- Naloxone can reverse buprenorphine-induced respiratory depression, but high doses may be required, and the reversal may be short-lived 5.
- Extended-release injectable buprenorphine (XR-buprenorphine) can be used to treat opioid use disorder, and its use has been shown to be safe and effective in the immediate post-naloxone period 8.