Buprenorphine/­naloxone may be recommended for socially stable people who use opioids who cannot retrieve medications from a center daily, who have another condition requiring regular primary care visits, or who have jobs or daily lives that require they maintain all their faculties and cannot take a sedating medication. Buprenorphine/­naloxone is also recommended over methadone for people who at high risk of methadone toxicity, such as the elderly, those taking high doses of benzodiazepines or other sedating substances, concomitant alcohol use disorder, those with a lower level of opioid tolerance, and those at high risk of prolonged QT interval. It is also helpful to use the medication in combination with psychosocial support and counseling. Available forms
Buprenorphine/naloxone is available in sublingual formulations (that is, products that are dissolved under the tongue). There is no evidence that the tablet formulation is easier to divert and use in ways other than intended by the prescriber compared to the film formulation, or that the tablet formulation has a higher risk for accidental ingestion by children. There are various pharmacokinetic differences between sublingual formulations. Contraindications
Contraindications are severe respiratory or liver impairment and acute alcoholism. There are limited accounts of cross-reactivity with opioids, but there is a possibility. Serious central nervous system (CNS) and respiratory depression may also occur with concurrent use of CNS depressants, ingesting alcohol, or other CNS-depressing factors while on buprenorphine/­naloxone. Adverse effects
Side effects are similar to those of buprenorphine and other opioids. In addition, naloxone can induce withdrawal symptoms in people who are addicted to opioids.
Buprenorphine/naloxone, sold under the brand name Suboxone among others, is a fixed-dose combination medication that includes buprenorphine and naloxone. It is used to treat opioid use disorder, and reduces the mortality of opioid use disorder by 50% (by reducing the risk of overdose on full-agonist opioids such as heroin or fentanyl). It relieves cravings to use and withdrawal symptoms. Buprenorphine/­naloxone is available for use in two different forms, under the tongue or in the cheek.Side effects may include respiratory depression (decreased breathing), small pupils, sleepiness, and low blood pressure. The risk of overdose with buprenorphine/­naloxone (unless combined with other sedating substances) is exceedingly low, and lower than with methadone, but people are more likely to stop treatment on buprenorphine/­naloxone than methadone. Buprenorphine (like methadone) is a treatment option during pregnancy. At lower doses, buprenorphine results in the usual opioid effects; high doses beyond a certain level do not result in greater effects. This is believed to result in a lower risk of overdose than some other opioids. Naloxone is an opioid antagonist that competes with and blocks the effect of other opioids (including buprenorphine) if given by injection. Naloxone is poorly absorbed when taken by mouth and is added to decrease the risk that people will misuse the medication by injection. Misuse by injection or use in the nose still occurs. Rates of misuse in the U.S. appear to be lower than with other opioids.The combination formulation was approved for medical use in the U.S. in 2002, and in the European Union in 2017.