There are multiple forms for buprenorphine (commonly called bupe), and this can prove confusing. Although we may never use most of these formulations in the emergency department, we should be familiar with them.
Sublingual Tablets and Film Strips
This is the primary formulation used in the emergency department and hospital as well as the most common form for those prescribed bupe for the treatment of opioid use disorder (OUD) and for patients who are prescribed bupe for pain. The film strips are preferred by my patients because they dissolve fast and tend to not taste too bitter.
The naloxone is included to prevent drug abusers from crushing the tab or strip and inhaling it or dissolving and injecting the medication. Naloxone has a very poor sublingual (SL) and oral bioavailability (less than 2 percent). However, naloxone has a very high intranasal and IV bioavailability, which is a deterrent to misuse of the medication. Patients and health care providers are often confused by the combination of bupe and naloxone because buprenorphine can precipitate withdrawal in opioid-dependent patients. However, buprenorphine-precipitated withdrawal is a feature of the pharmacology of bupe itself and has nothing to do with the naloxone component of Suboxone. When Suboxone is taken sublingually as intended, the naloxone has no bioavailability and no effect.
Bupe also has poor oral bioavailability—only about 15 percent if swallowed. Furthermore, it is important to remember that bupe tabs or strips must be placed sublingually, not anywhere else in the mouth; it’s not an oral dissolving tablet like ondansetron.
There is also a SL bupe mono-product, the most common brand name of which is Subutex, produced by Indivior, the same company that makes Suboxone. Subutex is only produced in tablet form. It is generally available in 2 mg and 8 mg strengths. Most generic forms are in the same dose formulations as the Suboxone or Subutex products (eg, 8 mg/2 mg or simply 8 mg, respectively).
When is the bupe mono-product indicated instead of the dual product? The most common clinical indication is pregnancy because the safety of routine naloxone exposure during pregnancy remains somewhat in question. However, recent small studies suggest the dual product is safe in pregnancy.1,2
The other common use of Subutex is in clinics, hospitals, etc., where the medication is administered by a nurse and there is no worry it will be crushed and injected. In my clinic and emergency department, we use only the generic mono-product bupe (administered by a nurse) because it is less expensive. We stock 8 mg and 2 mg SL tablets.