From the Guidelines
No, you should not give opioids with Suboxone (buprenorphine/naloxone) as this can be dangerous and counterproductive. Suboxone is a partial opioid agonist used to treat opioid dependence and contains naloxone, which blocks the effects of other opioids. Taking traditional opioids (like oxycodone, hydrocodone, morphine, or fentanyl) while on Suboxone typically results in one of two problematic outcomes: either the opioids won't work effectively because Suboxone blocks their effects, or they could potentially cause dangerous respiratory depression if taken in high doses attempting to overcome this blockade. Additionally, mixing these medications can trigger precipitated withdrawal if Suboxone is taken after recent opioid use 1.
For pain management while on Suboxone, consult your healthcare provider about non-opioid pain relief options or adjusting your Suboxone regimen. In emergency situations requiring opioid pain control, medical professionals may temporarily discontinue Suboxone and carefully monitor the patient while administering appropriate pain medication. It's also important to note that concomitant use of buprenorphine and QT-prolonging agents is contraindicated, and multiple drug-drug interactions resulting in QT-interval prolongation, serotonin syndrome, paralytic ileus, reduced analgesic effect, or precipitation of withdrawal symptoms are possible 1.
Some studies suggest that pain treatment with opioids is complicated by the high affinity of buprenorphine for the μ receptor, which risks displacement of, or competition with, full opioid agonist analgesics when buprenorphine is administered concurrently or sequentially 1. However, the most recent and highest quality study recommends individualizing the decision to continue or hold buprenorphine to the patient and clinical circumstances, taking into account the prescribed daily dose of buprenorphine, indication for buprenorphine treatment, risk of relapse, and expected level of postsurgical pain 1.
Key considerations for managing pain in patients on Suboxone include:
- Non-opioid pain relief options
- Adjusting the Suboxone regimen
- Temporarily discontinuing Suboxone in emergency situations
- Careful monitoring of the patient while administering pain medication
- Avoiding concomitant use of buprenorphine and QT-prolonging agents
- Being aware of potential drug-drug interactions and their consequences.
From the Research
Opioids and Suboxone Co-administration
- The co-administration of opioids with Suboxone (buprenorphine) is a complex topic, and the available evidence suggests that it can be done, but with caution 2, 3, 4, 5, 6.
- Buprenorphine, the active ingredient in Suboxone, is a partial opioid agonist that can precipitate withdrawal in individuals who are physically dependent on full opioid agonists, such as methadone or fentanyl 2, 5.
- However, studies have shown that buprenorphine can be used to reverse respiratory depression induced by full opioid agonists, and it may be a safer alternative to naloxone in some cases 2.
- The management of precipitated withdrawal induced by buprenorphine can be challenging, but some studies suggest that rapid increases in buprenorphine dose can be an effective treatment strategy 3.
- Novel initiation strategies, such as microdosing with buprenorphine, have emerged as a potential approach to avoid precipitated withdrawal and improve treatment outcomes for individuals with opioid use disorder 4, 6.
Key Considerations
- The timing of buprenorphine administration in relation to opioid use is critical, as recent fentanyl use can increase the risk of precipitated withdrawal 5.
- The dose and formulation of buprenorphine used can also impact the risk of precipitated withdrawal and the effectiveness of treatment 4, 6.
- Further research is needed to fully understand the pharmacokinetics of non-medical fentanyl use and to develop optimal buprenorphine induction strategies 5.