AdultPediatricDosage Forms & Strengths buprenorphine/naloxone film, sublingual: Schedule III 2mg/0.5mg (Suboxone, generic) 4mg/1mg (Suboxone, generic) 8mg/2mg (Suboxone, generic) 12mg/3mg (Suboxone, generic) 16mg/4mg (Cassipa) tablet, sublingual (Zubsolv): Schedule III 0.7mg/0.18mg 1.4mg/0.36mg 2.9mg/0.71mg 5.7mg/1.4mg 8.6mg/2.1mg 11.4mg/2.9mg buccal film (Bunavail): Schedule III 2.1mg/0.3mg 4.2mg/0.7mg 6.3mg/1mg tablet, sublingual (generic): Schedule III 2mg/0.5mg 8mg/2mg Opioid Dependence Induction (buprenorphine SL) Day 1: 4 mg SL initially; may be repeated after 2 hours if withdrawal symptoms are not relieved; not to exceed 8 mg Day 2: If no withdrawal symptoms are present, 4 mg SL; if withdrawal symptoms are present, dose is increased by 4 mg; if symptoms are not relieved after >2 hr, 4 mg is administered; not to exceed 16 mg SL Switch to buprenorphine/naloxone for unsupervised maintenance Induction (buprenorphine/naloxone [Suboxone]) Caution: buprenorphine/naloxone (Suboxone) induction is only for patients dependent on short-acting opioids (eg, heroin) and not for those dependent on long-acting opioids (eg, methadone); buprenorphine monotherapy is recommended for induction for long-acting opioids Day 1: 2 mg/0.5 mg or 4 mg/1 mg SL initially; may titrate upwards in 2-4 mg increments at 2 hr intervals, under supervision; not to exceed 8 mg/2 mg Day 2: Up to 16 mg/4 mg SL as a single daily dose Induction (buprenorphine/naloxone [Zubsolv]) Caution: buprenorphine/naloxone (Zubsolv) induction is only for patients dependent on short-acting opioids (eg, heroin) and not for those dependent on long-acting opioids (eg, methadone); buprenorphine monotherapy is recommended for induction for long-acting opioids Day 1 An induction dose of up to 5.7 mg/1.4 mg is recommended, given in divided doses; initiate with 1.4 mg/0.36 mg SL; give remainder of Day 1 dose of up to 4.2 mg/1.08 mg should be divided into doses of 1 to 2 tablets of 1.4 mg/0.36 mg at 1.5 to 2 hr intervals Some patients (eg, those with recent exposure to buprenorphine) may tolerate up to 3 x 1.4 mg/0.36 mg SL as a single, second dose Day 2 A single daily dose up to 11.4 mg/2.9 mg SL is recommended Induction (buprenorphine/naloxone [Bunavail]) Caution: buprenorphine/naloxone (Bunavail) induction is only for patients dependent on short-acting opioids (eg, heroin) and not for those dependent on long-acting opioids (eg, methadone); buprenorphine monotherapy is recommended for induction for long-acting opioids Day 1 The first dose should not be administered <6 hr after the patient last used an opioid An induction dose of up to 4.2 mg/0.7 mg is recommended; initiate with 2.1 mg/0.3 mg and repeat at ~2-hr, under supervision, to a total dose of 4.2 mg/0.7 mg based on control of acute withdrawal symptoms Day 2 A single daily dose up to 8.4 mg/1.4 mg buccal is recommended Maintenance Suboxone Target dose: 12-16 mg/4 mg buprenorphine/naloxone SL as a single daily dose Range: 16-24 mg buprenorphine component; not to exceed 32 mg/day Progressively adjust buprenorphine/naloxone dose in increments or decrements of 2 mg/0.5 mg or 4 mg/1 mg to level that holds patient in treatment and suppresses opioid withdrawal signs and symptoms Zubsolv Target dose: 11.4/2.9 mg as a single daily dose Range: 2.9/0.71 mg to 17.2/4.2 mg Progressively adjust buprenorphine/naloxone dose in increments or decrements of 1.4/0.36 mg or 2.9/0.71 mg to level that holds patient in treatment and suppresses opioid withdrawal signs and symptoms Bunavail Target dose: 8.4/1.4 mg as a single daily dose Range: 2.1/0.3 mg to 12.6/2.1 mg Progressively adjust dose in increments or decrements of 2.1/0.3 mg to a level that holds patient in treatment and suppresses opioid withdrawal signs and symptoms There is no maximum recommended duration of maintenance treatment; for some patients, treatment may continue indefinitely Cassipa Used after induction and stabilization of the patient, and after buprenorphine dose titrated to 16 mg using another marketed product If dose needs adjustment in order to maintain treatment and suppress opioid withdrawal signs and symptoms, a different product will be needed; Cassipa comes in a single dose and cannot be adjusted (ie, SL film available only as 16 mg buprenorphine/4 mg naloxone) There is no maximum recommended duration of maintenance treatment; for some patients, treatment may continue indefinitely Dosage Modifications Hepatic impairment Mild: No dosage adjustment necessary Moderate: May not be appropriate Severe: Avoid use Renal impairment No differences in buprenorphine pharmacokinetics observed between 9 dialysis-dependent and 6 normal patients following IV administration of 0.3 mg buprenorphine Renal failure: Unknown Dosing Considerations Prior to induction, consideration should be given to the type of opioid dependence (ie, long- or short-acting opioid products, the time since last opioid use, and the degree or level of opioid dependence To avoid precipitating an opioid withdrawal syndrome, the first dose of buprenorphine/naloxone should be administered only when objective and clear signs of moderate withdrawal are evident, and divided doses should be used It is recommended that an adequate treatment dose, titrated to clinical effectiveness, be achieved as rapidly as possible Patients dependent on methadone or long-acting opioid products may be more susceptible to precipitated and prolonged withdrawal during induction than those on short-acting opioid products; buprenorphine monotherapy is recommended in patients taking long-acting opioids instead of buprenorphine/naloxone, which may worsen withdrawal symptoms Patients dependent on heroin or other short-acting opioid products may be induced with buprenorphine/naloxone or with SL buprenorphine monotherapy Equivalents Zubsolv 5.7/1.4 mg SL provides equivalent buprenorphine exposure to Suboxone 8/2 mg SL Bunavail 2.1/0.3 mg buccal provides equivalent buprenorphine exposure to Suboxone 4/1 mg SL Bunavail 4.2/0.7 mg buccal provides equivalent buprenorphine exposure to Suboxone 8/2 mg SL Bunavail 6.3/1 mg buccal provides equivalent buprenorphine exposure to Suboxone 12/3 mg SL Access to naloxone for opioid overdose Assess need for naloxone upon initiating and renewing treatment Consider prescribing naloxone Based on patient’s risk factors for overdose (eg, concomitant use of CNS depressants, a history of opioid use disorder, prior opioid overdose); presence of risk factors should not prevent proper pain management Household members (including children) or other close contacts at risk for accidental ingestion or overdose Consult patients and caregivers on the following: Availability of naloxone for emergency treatment of opioid overdose Ways differ on how to obtain naloxone as permitted by individual state dispensing and prescribing requirements or guidelines (eg, by prescription, directly from a pharmacist, as part of a community-based program) Safety and efficacy not establishedInteraction CheckerEnter a drug name and buprenorphine/naloxoneNo Results No Interactions Found Interactions FoundContraindicatedSerious - Use AlternativeSignificant - Monitor CloselyMinorAll Interactions Sort By: SeverityName Contraindicated (5)alvimopanalvimopan, buprenorphine. receptor binding competition. Contraindicated. Alvimopan is contraindicated in opioid tolerant patients (ie, those who have taken therapeutic doses of opioids for >7 consecutive days immediately prior to taking alvimopan). Patients recently exposed to opioids are expected to be more sensitive to the effects of alvimopan and therefore may experience abdominal pain, nausea and vomiting, and diarrhea. No significant interaction is expected with concurrent use of opioid analgesics and alvimopan in patients who received opioid analgesics for 7 or fewer consecutive days prior to alvimopan.dronedaronebuprenorphine and dronedarone both increase QTc interval. Contraindicated.fezolinetantbuprenorphine will increase the level or effect of fezolinetant by affecting hepatic enzyme CYP1A2 metabolism. Contraindicated. Fezolinetant AUC and peak plasma concentration are increased if coadministered with drugs that are weak, moderate, or strong CYP1A2 inhibitorslefamulinlefamulin will increase the level or effect of buprenorphine by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Contraindicated. Lefamulin is contraindicated with CYP3A substrates know to prolong the QT interval.thioridazinebuprenorphine and thioridazine both increase QTc interval. Contraindicated.Serious - Use Alternative (132)abametapirabametapir will increase the level or effect of buprenorphine by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Avoid or Use Alternate Drug. If concomitant use is warranted, carefully monitor, particularly during treatment initiation and dose adjustment. Discontinue oliceridine if serotonin syndrome is suspected.acrivastineacrivastine and buprenorphine both increase sedation. Avoid or Use Alternate Drug. Limit use to patients for whom alternative treatment options are inadequatealfentanilbuprenorphine, alfentanil. Other (see comment). Avoid or Use Alternate Drug. Comment: Mixed opiate agonist/antagonists usually produce additive sedation with narcotics; however, in narcotic addicted pts., the antagonist activity may provoke withdrawal Sx.alfuzosinalfuzosin and buprenorphine both increase QTc interval. Avoid or Use Alternate Drug.amiodaronebuprenorphine and amiodarone both increase QTc interval. Avoid or Use Alternate Drug.amisulprideamisulpride and buprenorphine both increase QTc interval. Avoid or Use Alternate Drug. ECG monitoring is recommended if coadministered.amisulpride and buprenorphine both increase sedation. Avoid or Use Alternate Drug. Limit use to patients for whom alternative treatment options are inadequateamitriptylinebuprenorphine and amitriptyline both increase QTc interval. Avoid or Use Alternate Drug.amoxapinebuprenorphine and amoxapine both increase QTc interval. Avoid or Use Alternate Drug.anagrelideanagrelide and buprenorphine both increase QTc interval. Avoid or Use Alternate Drug.buprenorphine and anagrelide both increase QTc interval. Avoid or Use Alternate Drug.apalutamideapalutamide will decrease the level or effect of buprenorphine by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Avoid or Use Alternate Drug. Coadministration of apalutamide, a strong CYP3A4 inducer, with drugs that are CYP3A4 substrates can result in lower exposure to these medications. Avoid or substitute another drug for these medications when possible. Evaluate for loss of therapeutic effect if medication must be coadministered. Adjust dose according to prescribing information if needed.apomorphineapomorphine and buprenorphine both increase QTc interval. Avoid or Use Alternate Drug.aripiprazolearipiprazole and buprenorphine both increase QTc interval. Avoid or Use Alternate Drug.arsenic trioxidebuprenorphine and arsenic trioxide both increase QTc interval. Avoid or Use Alternate Drug.artemetherartemether and buprenorphine both increase QTc interval. Avoid or Use Alternate Drug.artemether/lumefantrineartemether/lumefantrine and buprenorphine both increase QTc interval. Avoid or Use Alternate Drug.asenapineasenapine and buprenorphine both increase QTc interval. Avoid or Use Alternate Drug.buprenorphine and asenapine both increase QTc interval. Avoid or Use Alternate Drug.asenapine and buprenorphine both increase sedation. Avoid or Use Alternate Drug. Limit use to patients for whom alternative treatment options are inadequateasenapine transdermalasenapine transdermal and buprenorphine both increase QTc interval. Avoid or Use Alternate Drug.asenapine transdermal and buprenorphine both increase sedation. Avoid or Use Alternate Drug. Limit use to patients for whom alternative treatment options are inadequateatomoxetineatomoxetine and buprenorphine both increase QTc interval. Avoid or Use Alternate Drug.avapritinibavapritinib and buprenorphine both increase sedation. Avoid or Use Alternate Drug. Limit use to patients for whom alternative treatment options are inadequateazithromycinbuprenorphine and azithromycin both increase QTc interval. Avoid or Use Alternate Drug.bedaquilinebedaquiline and buprenorphine both increase QTc interval. Avoid or Use Alternate Drug.belladonna and opiumbuprenorphine, belladonna and opium. Other (see comment). Avoid or Use Alternate Drug. Comment: Mixed opiate agonist/antagonists usually produce additive sedation with narcotics; however, in narcotic addicted pts., the antagonist activity may provoke withdrawal Sx.benzhydrocodone/acetaminophenbenzhydrocodone/acetaminophen, buprenorphine. Either increases toxicity of the other by pharmacodynamic synergism. Avoid or Use Alternate Drug. Profound sedation, respiratory depression, coma, and death may result if coadministered. Reserve concomitant prescribing of these drugs in patients for whom other treatment options are inadequate. Limit dosages and durations to the minimum required. Monitor closely for signs of respiratory depression and sedation.buprenorphine decreases effects of benzhydrocodone/acetaminophen by pharmacodynamic antagonism. Avoid or Use Alternate Drug. Mixed opioid agonists/antagonists and partial opioid agonists may reduce the analgesic effect of hydrocodone (benzhydrocodone prodrug of hydrocodone) and/or precipitate withdrawal symptoms in opioid tolerant patients.benzhydrocodone/acetaminophen and buprenorphine both increase sedation. Avoid or Use Alternate Drug. Limit use to patients for whom alternative treatment options are inadequatebremelanotidebremelanotide will decrease the level or effect of buprenorphine by Other (see comment). Avoid or Use Alternate Drug. Bremelanotide may slow gastric emptying and potentially reduces the rate and extent of absorption of concomitantly administered oral medications. Avoid use when taking any oral drug that is dependent on threshold concentrations for efficacy. Interactions listed are representative examples and do not include all possible clinical examples.brexpiprazolebrexpiprazole and buprenorphine both increase sedation. Avoid or Use Alternate Drug. Limit use to patients for whom alternative treatment options are inadequatebrimonidinebrimonidine and buprenorphine both increase sedation. Avoid or Use Alternate Drug. Limit use to patients for whom alternative treatment options are inadequatebrivaracetambrivaracetam and buprenorphine both increase sedation. Avoid or Use Alternate Drug. Limit use to patients for whom alternative treatment options are inadequatebuprenorphine subdermal implantbuprenorphine subdermal implant and buprenorphine both increase sedation. Avoid or Use Alternate Drug. Limit use to patients for whom alternative treatment options are inadequatebutorphanolbuprenorphine, butorphanol. Other (see comment). Avoid or Use Alternate Drug. Comment: Mixed opiate agonist/antagonists usually produce additive sedation with narcotics; however, in narcotic addicted pts., the antagonist activity may provoke withdrawal Sx.calcium/magnesium/potassium/sodium oxybatesbuprenorphine, calcium/magnesium/potassium/sodium oxybates. Either increases effects of the other by pharmacodynamic synergism. Avoid or Use Alternate Drug. Profound sedation, respiratory depression, coma, and death may result if coadministered. Reserve concomitant prescribing of these drugs in patients for whom other treatment options