Management overview for buprenorphine poisoning

This monograph discusses the management of buprenorphine poisoning. For the management of other acute opioid drug poisonings, see Opioid poisoning: general management. For advice for first responders to a patient with suspected opioid poisoning in the community or primary healthcare setting, see here.

Specific management is given for the following other opioids:

tramadol, which is also an inhibitor of serotonin and noradrenaline reuptake
tapentadol, which is also an inhibitor of noradrenaline reuptake.

Buprenorphine is a highly potent opioid with partial agonist activity. Because of its high first-pass metabolism, it is given sublingually, as a transdermal patch, or a depot injection. Sublingual preparations are used to manage opioid dependence, while transdermal patches are usually used for pain management. Sublingual preparations contain either buprenorphine alone or buprenorphine in coformulation with naloxone, an opioid antagonist.

Buprenorphine toxicity can occur from:

ingestion of sublingual tablets or transdermal patches—these preparations have some oral absorption and can cause toxicity if ingested in high doses
simultaneous application of multiple patches
diversion of buprenorphine for illicit intravenous use.

In a person with opioid-dependence, intravenous injection of the sublingual coformulation of buprenorphine and naloxone can precipitate acute opioid withdrawal due to the naloxone component. This is followed by buprenorphine poisoning when the effect of naloxone wears off.

Buprenorphine poisoning can cause respiratory depression that is disproportionately severe compared with its sedative effect. Most significant buprenorphine poisonings occurs in opioid-naive people, particularly children who ingest an adult’s medication.

First-line management of buprenorphine poisoning is support of airway and breathing. The opioid antagonist, naloxone, is used to reverse the effects of the opioid in patients with hypoventilation. In patients with hypoventilation, higher doses of naloxone may be required to reverse the effects of buprenorphine than for other opioid poisonings. Buprenorphine has a long duration of action, so death can occur many hours after ingestion. Patients with buprenorphine poisoning require prolonged observation.

Seek advice from a clinical toxicologist or poisons information centre (13 11 26) for patients:

with suspected buprenorphine poisoning who do not respond to naloxone
who have co-ingested other drugs with buprenorphine
who require a prolonged naloxone infusion.