Suboxone Disease Interactions

Buprenorphine exposes users to the risks of addiction, abuse, and misuse. Each patient's risk should be assessed before prescribing buprenorphine analgesics, and all patients should be monitored regularly for development of such behaviors and conditions. Risks are increased in patients with personal or family history of substance abuse (including drug or alcohol abuse or addiction) or mental illness (e.g., major depression); the potential for such risks should not prevent proper pain management in any given patient. Patients at increased risk may be prescribed buprenorphine analgesics but use in such patients requires intensive counseling about the risks and proper use of buprenorphine, as well as intensive monitoring for signs of addiction, abuse, and misuse; prescribing naloxone for the emergency treatment of opioid overdose should be considered. All patients using buprenorphine for opioid dependence should be monitored for progression of opioid use disorder and addictive behaviors.

Buprenorphine is sought for nonmedical use (including by individuals with opioid use disorder) and is subject to criminal diversion. These risks should be considered when prescribing or dispensing buprenorphine. Strategies to reduce such risks should be used (e.g., prescribe smallest appropriate quantity, careful storage during use, proper disposal of unused drug).

Buprenorphine analgesics are contraindicated in patients with significant respiratory depression. Serious, life-threatening, or fatal respiratory depression may occur with buprenorphine. Patients should be monitored closely for respiratory depression, especially during initiation of therapy or after a dosage increase. Prescribing naloxone for the emergency treatment of opioid overdose should be considered; however, naloxone may not be effective in reversing respiratory depression produced by buprenorphine due to its slow rate of dissociation from mu receptors.

The use of buprenorphine analgesics in patients with acute or severe bronchial asthma in an unmonitored setting or without resuscitative equipment is contraindicated. Buprenorphine-treated patients with significant chronic obstructive pulmonary disease or cor pulmonale, and those with substantially decreased respiratory reserve, hypoxia, hypercapnia, or preexisting respiratory depression are at increased risk of decreased respiratory drive (including apnea), even at recommended dosages of buprenorphine analgesics; buprenorphine for opioid dependence should be used with caution in such patients with compromised respiratory function. In patients who may be susceptible to the intracranial effects of carbon dioxide (CO2) retention (e.g., those with evidence of increased intracranial pressure or brain tumors), buprenorphine analgesics may reduce respiratory drive, and the resulting CO2 retention can further increase intracranial pressure; these patients should be monitored for signs of sedation and respiratory depression, especially when starting therapy. Buprenorphine for opioid dependence should be used with caution in patients with head injury, intracranial lesions, and other circumstances where cerebrospinal pressure may be increased. Opioids may obscure the clinical course in a patient with a head injury; use of buprenorphine analgesics should be avoided in patients with impaired consciousness or coma.

Life-threatening respiratory depression is more likely to occur in older adult, cachectic, or debilitated patients as they may have altered pharmacokinetics (or altered clearance) compared to younger, healthier patients. These patients should be monitored closely, especially when starting and titrating buprenorphine analgesics and when coadministering with other drugs that depress respiration; alternatively, the use of nonopioid analgesics should be considered. Buprenorphine should be used with caution in patients with kyphoscoliosis.

Therapy with naloxone in patients with preexisting cardiovascular disorders should be closely monitored for hypotension, hypertension, ventricular tachycardia or fibrillation, and pulmonary edema in an appropriate healthcare setting. Clinical monitoring of cardiovascular status is recommended.

Opioid analgesics are contraindicated in patients with known or suspected gastrointestinal obstruction, including paralytic ileus.

The hypoventilation associated with administration of opioid partial agonists can induce cerebral hypoxia and vasodilatation with resultant increase in intracranial pressure. Unless mechanical ventilation is provided, extreme caution is advised when opioid partial agonists are given to patients with head injury, intracranial lesions, or a preexisting elevated CSF pressure. Also, clinicians treating such patients should be aware that opioid partial agonists may interfere with the evaluation of CNS function, especially with respect to consciousness levels, respiratory status, and pupillary changes.

Buprenorphine should be used with caution in patients with adrenal insufficiency (e.g., Addison's disease). Cases of adrenal insufficiency have been reported with opioid use, more often with use beyond 1 month. If adrenal insufficiency has occurred with a particular opioid, other opioids may be tried as some cases reported use of a different opioid without recurrence of adrenal insufficiency. Available information does not identify which opioids are more likely to be associated with adrenal insufficiency.

Buprenorphine may cause severe hypotension (including orthostatic hypotension, syncope) in ambulatory patients. Risk is increased in patients whose ability to maintain blood pressure has already been compromised by reduced blood volume or coadministration of certain CNS depressant drugs; these patients should be monitored for signs of hypotension after starting or titrating buprenorphine. In patients with circulatory shock, buprenorphine may cause vasodilation that can further reduce cardiac output and blood pressure; buprenorphine analgesics should be avoided in patients with circulatory shock.

Buprenorphine is metabolized in the liver, and its activity may be increased and/or extended in patients with impaired liver function.
-Buccal film or sublingual tablets: A dose adjustment is recommended for patients with severe liver dysfunction; patients with moderate or severe liver dysfunction should be periodically assessed for signs/symptoms of toxicity or overdose caused by increased buprenorphine levels.
-IM/IV injection: This product should be administered with caution in patients with severe liver dysfunction.
-Subcutaneous injection or subdermal implant: The effect of liver dysfunction on the pharmacokinetics of this product has not been studied. Due to the long-acting nature of the subcutaneous injection, dosage adjustments are not rapidly reflected in plasma buprenorphine levels. Because buprenorphine levels cannot be rapidly adjusted when using the subcutaneous injection, and because the subdermal implant cannot be titrated, patients with preexisting moderate to severe liver dysfunction are not candidates for treatment with these products.
-Transdermal system: This product has not been evaluated in patients with severe liver dysfunction; because this product is only intended for 7-day application, use of an alternate analgesic that may permit more flexibility with dosing in these patients should be considered.

Thorough QT studies with buprenorphine have shown QT prolongation 15 msec or less; this QTc prolongation effect does not appear to be mediated by hERG channels. Based on these 2 findings, buprenorphine is unlikely to be proarrhythmic when used alone in patients without risk factors. However, these observations should be considered in clinical decisions when prescribing buprenorphine to patients with risk factors (e.g., hypokalemia, bradycardia, recent conversion from atrial fibrillation, congestive heart failure, baseline QT prolongation, subclinical long-QT syndrome, severe hypomagnesemia).

Buprenorphine is substantially excreted by the kidney; the risk of adverse reactions to this drug may be greater in patients with impaired renal function. Buprenorphine has not been studied in patients with renal dysfunction; caution is recommended when used in patients with severe renal dysfunction.

Buprenorphine should be used with caution in patients with prostatic hypertrophy or urethral stricture. Urinary retention has been reported with buprenorphine.

The safety and effectiveness of naloxone injection in patients with liver disease have not been established. Caution should be exercised when naloxone is administered to patients with liver disease.

The safety and effectiveness of naloxone injection in patients with renal insufficiency/failure have not been established. Caution should be exercised when naloxone is administered to these patients.

Naloxone has been shown in some cases of septic shock to produce a rise in blood pressure that may last up to several hours; however, this pressor response has not been demonstrated to improve patient survival. In some studies, treatment with naloxone in the setting of septic shock has been associated with adverse effects, including agitation, nausea and vomiting, pulmonary edema, hypotension, cardiac arrhythmias, and seizures. The decision to use naloxone in septic shock should be exercised with caution, particularly in patients who may have underlying pain or have previously received opioid therapy and may have developed opioid tolerance.

Narcotic (opioid) analgesic agents may increase the frequency of seizures in patients with seizure disorders, may increase the risk of seizures occurring in other clinical settings associated with seizures, and, at higher dosages, have been reported to induce seizures in patients without history of seizures. Patients with history of seizure disorders should be regularly evaluated for worsened seizure control during therapy. Prolonged meperidine use may increase the risk of toxicity (e.g., seizures) from the accumulation of the active metabolite (normeperidine).

Opioid agonists may cause spasm of the sphincter of Oddi, which may increase biliary tract pressure. Other opioid-induced effects may include a reduction in biliary and pancreatic secretions and transient elevations in serum amylase. Patients with biliary tract disease (including acute pancreatitis) should be regularly evaluated for worsening symptoms. Therapy with opioids should be administered cautiously in patients with biliary tract disease, gallbladder disease, or acute pancreatitis.