Buprenorphine (Opioid Dependence)

How it works

It is a partial agonist at mu-opioid receptors with high receptor affinity and slow dissociation, suppressing withdrawal and craving while producing a ceiling on respiratory depression and euphoria.

Prescribing in practice

• Because of its high mu-receptor affinity, the first dose must be given only when objective withdrawal features have emerged, otherwise it can precipitate acute opioid withdrawal in a still-dependent patient.
• Risk of respiratory depression and death is greatest when combined with other CNS depressants, particularly benzodiazepines, alcohol and other opioids.
• Initiation and titration should be supervised, with arrangements for supervised consumption and confirmation of dependence before starting.

Monitoring

Monitor for adequacy of withdrawal/craving control, signs of sedation or diversion, concurrent substance use, and liver function where clinically indicated.

Counselling the patient

• Do not take your first dose until you are clearly in withdrawal, or it may make you feel much worse.
• Combining this with alcohol, sleeping tablets or street opioids can stop your breathing.
• Let the tablet or film dissolve fully under the tongue and do not swallow it.

Evidence & guidelines

NICE guidance supports opioid substitution treatment with buprenorphine or methadone as part of a structured maintenance and recovery programme.