Why Would a Patient Take Percocet and Suboxone Together?
A patient with chronic pain and opioid use disorder would take Percocet (oxycodone/acetaminophen) and Suboxone (buprenorphine/naloxone) together because buprenorphine's high affinity for mu-opioid receptors requires additional full opioid agonists to achieve adequate analgesia for acute or breakthrough pain, though this combination requires careful monitoring due to competitive receptor binding and increased overdose risk. 1
Clinical Scenarios for Concurrent Use
Acute Pain Management in Patients on Buprenorphine Maintenance
When patients receiving buprenorphine maintenance therapy develop acute pain requiring opioid analgesia, several evidence-based approaches exist:
Continue buprenorphine and add short-acting opioids: The most common approach is to maintain the patient's buprenorphine dose while titrating a full opioid agonist like oxycodone (Percocet) to effect. 1 However, higher doses of the full agonist may be required because buprenorphine's high mu-receptor affinity creates competitive binding that blocks some analgesic effects. 1
Divided dosing strategy: The daily buprenorphine dose can be divided and administered every 6-8 hours to leverage its analgesic properties, though additional full agonist analgesics may still be needed for patients with opioid tolerance. 1
Critical Safety Considerations
Naloxone must be readily available and respiratory status frequently monitored because buprenorphine dissociates from mu-receptors at highly variable rates, creating unpredictable responses when combined with full agonists. 1
The risk of respiratory depression increases when full agonists are added to buprenorphine therapy, particularly if buprenorphine is abruptly discontinued, as patients may develop increased sensitivity to the full agonist's sedative and respiratory depressant effects. 1
Acetaminophen toxicity risk: Combination products like Percocet containing fixed-dose acetaminophen should be limited in patients requiring large opioid doses to avoid hepatic toxicity. 1 Prescribing oxycodone and acetaminophen separately allows appropriate analgesic dosing while preventing liver damage. 1
Chronic Pain with Comorbid Opioid Use Disorder
Dual Diagnosis Management
Patients may be prescribed both medications when they have:
Chronic pain requiring ongoing management while simultaneously being treated for opioid use disorder with buprenorphine/naloxone maintenance therapy. 1
Complex persistent opioid dependence: Some patients on high-dose opioids for chronic pain experience poor analgesia and function despite substantial doses, yet worsen when opioids are reduced or increased. 1 These patients often have comorbid mood disorders but don't meet full criteria for opioid use disorder. 1
Buprenorphine as Analgesic
Buprenorphine/naloxone has been used off-label as an analgesic for chronic pain, with evidence suggesting efficacy in patients with comorbid chronic pain and opioid use disorder. 1 Some patients experience substantial improvements in pain and quality of life when switched from full mu-opioid agonists to buprenorphine. 1
Important Clinical Pitfalls
Precipitated Withdrawal Risk
Buprenorphine should only be administered to patients in active opioid withdrawal as confirmed by history and physical examination. 1 Because of its high binding affinity and partial agonist properties, administering buprenorphine to patients currently receiving full agonist opioids who are not yet in withdrawal can induce significant withdrawal symptoms. 1
Medication Interactions and Monitoring
Avoid concurrent benzodiazepines: The CDC strongly recommends avoiding co-prescription of opioids and benzodiazepines whenever possible due to 3-10 fold increased risk of fatal overdose. 1 This applies whether the opioid is a full agonist like oxycodone or a partial agonist like buprenorphine. 2
Prescription drug monitoring programs (PDMPs): Clinicians should review PDMP data before prescribing to identify dangerous combinations and multiple prescribers. 1 If patients receive opioids from multiple sources, discuss safety concerns directly with the patient and coordinate care with other prescribers. 1
Urine drug testing: Use drug testing before starting opioid therapy and at least annually to assess for prescribed medications and illicit substances that increase overdose risk. 1
Treatment Coordination
When patients require both medications, clinicians should:
Notify the buprenorphine maintenance program if the patient is hospitalized, making staff aware of controlled substances administered that may appear on drug testing. 1
Calculate total morphine milligram equivalents (MME) for all concurrent opioid prescriptions and consider tapering to safer dosages if totals are high. 1
Offer evidence-based treatment for opioid use disorder: Medication-assisted treatment with buprenorphine or methadone combined with behavioral therapies is the most effective approach for opioid use disorder, reducing overdose death likelihood up to threefold. 1, 3
Alternative Approaches
Rather than combining medications, consider:
Discontinuing buprenorphine temporarily: For severe acute pain, discontinue buprenorphine and treat with scheduled full opioid agonist analgesics, then resume buprenorphine using an induction protocol once acute pain resolves. 1
Non-opioid therapies: Prioritize non-opioid analgesic therapies (both pharmacologic and non-pharmacologic) as initial treatment for chronic pain. 1