Buprenorphine (better known as the active ingredient in Suboxone) has helped many addicted to other opioids get their lives back, but the drug's unique properties should also make us consider using it instead of naloxone to reverse opioid overdose.
When used for medication assisted treatment (MAT), buprenorphine has the advantage over methadone of blocking the effects of other opioids, and when administering the drug for the first time, it will force a patient still addicted into withdrawal, so it will likely produce a similar effect in cases of opioid overdose. Overdose with buprenorphine alone, unlike other opioids, rarely causes death, so the risk of worsening a buprenorphine overdose by administering a small additional dose would seem minimal.
Naloxone (most commonly branded as Narcan) effectively reverses overdose, but since this effect wears off quickly, many patients have died when the drug with which they overdosed, heroin, for example, remained active at toxic levels. This effect of buprenorphine, on the other hand, may persist, even rendering the patient unable to obtain effect from further administration of opioids after the overdose drug has worn off. Furthermore, in effect, the patient has started MAT. If afforded the opportunity to continue this life-saving treatment, they may have launched their recovery.
Unlike naloxone, buprenorphine does not require a bulky syringe for administration. A sublingual film strip takes up less space than a credit card in your wallet. Even if not stored or carried in anticipation of need to reverse an overdose, buprenorphine may be available on the street or in the home of an MAT patient when naloxone cannot be found in time. Even without training one might easily and safely administer a buprenorphine film strip by placing it under the tongue, even of an unconscious patient. (As of this writing, in the U.S., buprenorphine film, either Suboxone or generic, also includes naloxone, but the naloxone will not enter the bloodstream through the oral mucosa.)
This case report documents use of buprenorphine to reverse an overdose, and this paper documents the risks (and one success) of intravenous administration of buprenorphine dissolved from a sublingual tablet, but we need much more study. For example, we need to know whether buprenorphine will reverse a fentanyl overdose, and we need to establish an optimal dose.
Buprenorphine's status as a Schedule III controlled substance should not stand in the way of saving lives. I challenge researchers and regulators to move quickly to enable wider use of this drug to reverse opioid overdoses.
Berry Edwards, MD