Partial Opioid Agonist (Opioid Substitution Therapy) Pregnancy: Compatible in pregnancy (Subutex/Suboxone) — continued OST essential to prevent relapse; monitor for neonatal abstinence syndrome

Buprenorphine (Opioid Dependence)

Brand names: Subutex (SL tablet), Suboxone (buprenorphine + naloxone SL film)

Adult dose

Dose: Induction: 0.8–4 mg SL on day 1 (start when in mild withdrawal — COWS score ≥8). Titrate by 2–4 mg daily. Maintenance: 8–24 mg/day SL. Maximum licensed: 32 mg/day.

Route: Sublingual (SL) — must dissolve under tongue, not swallowed

Frequency: OD (or BD in some patients)

Max: 32 mg/day

Suboxone contains naloxone to discourage IV diversion (naloxone is poorly absorbed SL; systemically active if injected). Never swallow — bioavailability minimal orally. Must be in mild withdrawal at induction (not in precipitated withdrawal).

Paediatric dose

Route: N/A

Frequency: N/A

Max: Not licensed in children/adolescents

Not established for opioid dependence in patients <18 years

Dose adjustments

Renal

No dose adjustment required

Hepatic

Caution in hepatic impairment — buprenorphine extensively metabolised; elevated LFTs common in opioid users, especially with hepatitis C

Clinical pearls

Induction timing: start when COWS score ≥8 (Clinical Opiate Withdrawal Scale) — mild withdrawal ensures no precipitation of acute withdrawal from receptor displacement
Ceiling effect: buprenorphine has ceiling effect on respiratory depression (safer than full agonists at high doses)
Suboxone vs Subutex: Suboxone preferred (contains naloxone) to reduce IV diversion; Subutex reserved for those allergic to naloxone or in pregnancy
Pregnancy: buprenorphine (without naloxone — Subutex) maintained through pregnancy; neonatal abstinence syndrome (NAS) managed with morphine; benefits of treatment outweigh NAS risk

Contraindications

Not in full opioid withdrawal state without mild symptoms (precipitated severe withdrawal)
Severe hepatic impairment
Respiratory failure

Side effects

Constipation
Nausea
Headache
Insomnia
Sweating
Precipitated withdrawal (if too early induction)
Hepatitis (especially in hepatitis C co-infection — monitor LFTs)
Dental caries (Subutex — from acidic SL dissolution)

Interactions

CNS depressants, particularly benzodiazepines — respiratory depression (significant — buprenorphine + benzodiazepine deaths reported)
Naltrexone — precipitates withdrawal (reverse order)

Monitoring

Urine drug screens
LFTs
COWS score at induction
Adherence and supervised consumption compliance
Dental hygiene (SL film erosion)

Reference: BNFc; BNF; NICE NG58; Drug Misuse and Dependence: UK Clinical Guidelines (Orange Guidelines). Verify against your local formulary and the latest BNF before prescribing.

Curated clinical cross-links plus same-class fallbacks.

Calculators

Pathways