Buprenorphine is a semisynthetic opioid that is used at varying doses either to treat opioid addiction or to control acute or chronic pain. Brand names of buprenorphine include; Buprenex, Subutex and Suboxone (with naloxone). It is metabolised by CYP 3A4 and interacts with HIV protease inhibitors and antifungals (azoles) resulting in increased buprenorphine concentrations.
In the Netherlands, buprenorphine is a List II drug of the Opium Law. It is a Schedule III drug in the United States under the United Nations’ Convention on Psychotropic Substances.
Adverse effects of buprenorphine include the following;
- Memory loss
- Urinary retention
- Respiratory depression
- Cognitive and neural inhibition
- Dry mouth
- Decreased libido
- Orthostatic hypotension
- Male ejaculatory difficulty
Patients on medium to long-term maintenance with Suboxone or Subutex do not have a risk of overdose from buprenorphine alone, due to the “ceiling effect” on respiratory depression. With these patients, overdoses occur due to multiple-drug intoxication, usually buprenorphine taken with excessive amounts of ethanol and/or benzodiazepine drugs.
Buprenorphine is also used recreationally, typically by opioid users, often by insufflation (inhaling). Suboxone tablets can be crushed and snorted and users report a euphoric rush similar to other opioids with a slight “upper”-like effect.
Buprenorphine abuse is common in Scandinavia, especially in Finland and Sweden. In 2007, authorities in Uppsala County in Sweden confiscated more buprenorphine than cocaine, ecstasy or heroin. Recreational use of buprenorphine is on the rise in Finland. In 2005, Finland’s incidence of Subutex abuse surpassed the incidence of recreational usage of amphetamines (most often injected intravenously).
Street names of buprenorphine in the United States include; Sobos, Sibbies, Sibs, Bupe, Stops, Stop Signs, Box, Oranges, Sub, Subs and Texas Toast .In the United Kingdom street names include; Subway, Subbies, Tems, Gesics, Xone, Subs and Bupey. In Australia it is referred to as; Silverbacks, Bupe, poor man’s Smack and S Box.
Biological samples which can be taken from the body for testing for buprenorphine by a forensic toxicologist include the following;
Lethal levels of buprenorphine which can be detected within these samples by a forensic toxicologist are outlined in the table below;
(Adapted from Molina 2010:45)
New research suggests that when it comes to safety, buprenorphine has the advantage over Methadone for patients with chronic pain and comorbid opioid addiction. Anne Neumann PhD, from the Addiction Medicine Program in the Department of Family Medicine at the State University of New York at Buffalo, and colleagues presented their findings at the American Society of Addiction Medicine (ASAM) 43rd Annual Medical-Scientific Conference. The randomised clinical trial compared buprenorphine treatment with methadone treatment in chronic pain patients with opioid addiction over a treatment period of six months.
“Methadone treatment resulted in less opioid use than buprenorphine treatment (0 vs. 5 patients, respectively). However, buprenorphine treatment had a superior safety profile compared with methadone treatment, owing to its reduced likelihood of overdose death and respiratory depression.” (Medscape)
Herbert L. Malinoff, MD, commented that the study suggests methadone and buprenorphine appear to have equal efficacy in the treatment of chronic pain in opioid addicted patients, but buprenorphine has safety advantages;
“Clinicians may choose to use buprenorphine in an office-based setting to treat pain in their opioid-addicted patients rather than referring them to federally licensed methadone clinics.” (Malinoff)
American Society of Addiction Medicine (ASAM) 43rd Annual Medical-Scientific Conference. Abstract P7, presented April 20, 2012.
Molina, D.K. (2010). Handbook of Forensic Toxicology for Medical Examiners. CRC Press : Boca Raton
www.medscape.com – Article by Emma Hitt, PhD