Buprenorphine for medication-assisted treatment of opioid dependence (MATOD)

Buprenorphine is a safe and effective treatment for medication-assisted treatment of opioid dependence (MATOD). It is used sublingually or subcutaneously in higher doses than those used for analgesia.

The characteristics of buprenorphine preparations are outlined in Preparations of buprenorphine for medication-assisted treatment of opioid dependence (MATOD). Therapy can be started using either a sublingual preparation or a weekly modified-release subcutaneous preparation; maintenance therapy can be with either a sublingual or modified-release (weekly or monthly) subcutaneous injection.

For a comparison of buprenorphine with methadone, see Comparison of buprenorphine and methadone in medication-assisted treatment of opioid dependence (MATOD).

For considerations before starting buprenorphine, see Patient evaluation before starting MATOD and Legal and practical requirements before starting MATOD. Contact with a specialist advisory service is encouraged.

Note: Specialist advice on prescribing buprenorphine is available by phone and contact is encouraged.

Table 1. Preparations of buprenorphine for medication-assisted treatment of opioid dependence (MATOD)Printable table
sublingual preparations (brand names): buprenorphine+naloxone film (Suboxone) buprenorphine tablet (Subutex) modified-release subcutaneous preparations (brand names): buprenorphine injection (Buvidal Weekly) buprenorphine injection (Buvidal Monthly) buprenorphine injection (Sublocade)
sublingual buprenorphine+naloxone film (Suboxone)
Frequency of administration	daily or on alternate days
Available strengths	2+0.5 mg; 8+2 mg
Indication	initiation and maintenance of MATOD
Advantages	less risk of being injected than Subutex [NB1]RADAR, 2011 dissolves faster than Subutex tabletsRADAR, 2011
Considerations	naloxone is contraindicated in liver failure
sublingual buprenorphine tablet (Subutex)
Frequency of administration	daily or on alternate days
Available strengths	0.4 mg; 2 mg; 8 mg
Indication	initiation and maintenance of MATOD
Advantages	preferred over Suboxone in liver failure and in some pregnant patients
Considerations	not available in some states and territories unless patient is pregnant or has a specific additional indication (eg allergy to naloxone) fewer takeaway doses permitted for Subutex than for Suboxone
modified-release subcutaneous buprenorphine injection (Buvidal Weekly)
Frequency of administration	weekly
Available strengths	8 mg/0.16 mL; 16 mg/0.32 mL; 24 mg/0.48 mL; 32 mg/0.64 mL
Indication	initiation and maintenance of MATOD. Some state and territory guidelines suggest starting after a patient has had a short trial (eg 7 days) of sublingual buprenorphine
Advantages	less frequent attendance for dosing frees people to engage with other life activities
Considerations	strategies might be needed to minimise pain on injection [NB2] some patients have cosmetic concerns about the visible lumps resulting from the volume of the injection
modified-release subcutaneous buprenorphine injection (Buvidal Monthly)
Frequency of administration	monthly
Available strengths	64 mg/0.18 mL; 96 mg/0.27 mL; 128 mg/0.36 mL; 160 mg/0.45 mL
Indication	maintenance of MATOD after initiating therapy with Buvidal Weekly or sublingual buprenorphine
Advantages	less frequent attendance for dosing frees people to engage with other life activities
Considerations	strategies may be needed to minimise pain on injection [NB2] some patients have cosmetic concerns about the visible lumps resulting from the volume of the injection
modified-release subcutaneous buprenorphine injection (Sublocade)
Frequency of administration	monthly
Available strengths	100 mg/0.5 mL; 300 mg/1.5 mL
Indication	maintenance of MATOD after initiating therapy with sublingual or subcutaneous buprenorphine
Advantages	less frequent attendance for dosing frees people to engage with other life activities duration of action is the longest of the monthly formulations, which may add to its convenience
Considerations	strategies might be needed to minimise pain on injection [NB2] some patients have cosmetic concerns about the visible lumps resulting from the volume of the injection
Note: NB1: Naloxone is added to discourage injection. Injected naloxone may precipitate opioid withdrawal, but sublingual naloxone is much less likely to do so because it is poorly absorbed. NB2: Pain may be reduced with use of cold packs and local anaesthetic.

Buprenorphine can precipitate withdrawal if started too soon after the last use of a more potent opioid. This is because buprenorphine can displace the other opioid from mu receptors but results in less stimulation of the receptor (partial agonism). For patients who have been using heroin or other short-acting opioids (eg morphine, oxycodone), buprenorphine should be started after the effects of the previous opioid have subsided to the extent that mild to moderate withdrawal is evident (from signs such as sweating and dilated pupils). If patients are transferring from longer-acting opioids (eg methadone) to buprenorphine, seek specialist advice from a clinical advisory service.

Note: Buprenorphine can precipitate withdrawal if used too soon after the last opioid dose.