a 20-year - old incarcerated indigenous australian male , with a history of hepatitis c and intravenous drug abuse , was admitted to the intensive care unit with fulminant hepatic failure following a 5-day history of jaundice , nausea , and vomiting .
the patient was opioid dependent but had been previously well with no relevant medical history .
investigations at the time of presentation revealed a severe acute hepatitis with marked synthetic dysfunction .
his arterial lactate was 5.6  mmol / l , ph was 7.5 and serum ammonia was 132 
viral serology revealed positive hepatitis c virus ( hcv ) antibodies and evidence of immunity to hepatitis b virus .
corroborative history from prison medical staff revealed that the patient had thrice injected buprenorphine 1  day prior to the onset of his symptoms .
the patient developed life - threatening multiorgan failure as a consequence of the fulminant hepatic failure and met listing criteria for liver transplantation .
the patient was managed as per the american association for the study of liver diseases acute liver failure guidelines 1 .
he was commenced on broad - spectrum antibiotics , antifungal prophylaxis , an n - acetyl - cysteine infusion and continuous veno - venous hemofiltration .
the patient survived with supportive intensive care management and was discharged from hospital after 42  days . upon discharge , his liver function was improving with an alt of 278  u / l , inr of 1.2 , albumin of 24  g / l and serum bilirubin of 367  mol / l , having peaked at 450  mol / l .
buprenorphine is a potent semisynthetic opioid derivative that is prescribed for the treatment of opioid dependence or for analgesic purposes .
it undergoes extensive first pass hepatic metabolism utilizing the p450 ( cyp 3a4 ) system 2 .
acute liver injury from the misuse of sublingual buprenorphine has been described in several case reports and case series .
almost all cases of significant hepatocellular injury have been associated with hepatitis c viremia 37 .
it has been postulated that hcv induces mitochondrial toxicity , leading to more significant liver damage .
the spectrum of hepatotoxicity following therapeutic administration , misuse or overdose of buprenorphine ranges from a mild - to - severe hepatitis .
the majority of reported cases of intravenous buprenorphine - associated liver damage have been in the context of known or recently detected hepatitis c infection .
although intravenous buprenorphine - induced hepatitis is now well recognized , life - threatening fulminant hepatic failure due to this drug has not previously been reported .
acute liver injury from intravenous buprenorphine use has been primarily attributed due to the high parenteral doses obtained from crushed sublingual tablets .
the mechanism of toxicity is due to inhibition of mitochondrial respiration and fatty acid - b oxidation , leading to atp depletion and hepatocyte necrosis , in rat models 2 .
most patients who have restarted conventional sublingual doses following an episode of toxicity have not had recurrent liver injury 3,5 .
the prevalence of hepatitis c virus ( hcv ) infections is high among opioid - dependent individuals .
care needs to be undertaken when prescribing the newer classes of protease inhibitors ; simeprevir , telaprevir , and boceprevir that are metabolized via the p450 system .
in addition , the effect of alcohol on the liver contributes to the altered metabolism of buprenorphine via the cyp3a4 enzyme 8 .
the additive cns respiratory depressant effects of this combination have been fatal in overdose 9 .
the possibility of intravenous misuse and drug interactions should not prevent clinicians from considering sublingual buprenorphine as a maintenance treatment for heroin addiction .
however , caution should be applied in patients with chronic hcv infection and who are at risk of intravenous misuse .
 key clinical messagea 20-year - old indigenous australian male was admitted to the intensive care unit with fulminant hepatic failure secondary to intravenous use of buprenorphine , which had been prescribed sublingually for opioid dependence . 
 intravenous buprenorphine - induced hepatitis is well recognized , however , life - threatening fulminant hepatic failure has not previously been reported . 
Introduction
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