Subutex is a brand name formulation of the semi-synthetic opioid buprenorphine, used only for the treatment of opioid use disorder. It comes as a sublingual tablet, which is dissolved under the tongue.
Subutex has a variety of pharmacological properties that make it less likely to be abused and less likely to cause fatal overdose. Nevertheless, buprenorphine is the most abused prescription opioid in the United States.
Can You Overdose on Subutex?
Yes, overdose can occur with Subutex. At first glance, it may sound like Subutex can easily cause overdose because it is 25–100 times more potent than morphine. However, Subutex has certain pharmacological properties that make overdose less likely:
- Ceiling Effect: Respiratory suppression reaches a plateau and doesn’t increase with increasing doses
- Partial Opioid Agonist: Buprenorphine binds to opioid receptors but has very little opioid activity, so it has a much lower risk of respiratory suppression (the main cause of death in opioid overdose) than do other opioids
- Poor Oral Absorption: If Subutex is swallowed inadvertently (by children, for example), it has very little absorption from the gut, making overdose highly unlikely
Overdoses from Subutex alone are not common, and most overdose deaths occur when the drug is used with sedatives, especially benzodiazepines.
One large study showed that buprenorphine-containing drugs are six times less likely to cause overdose than methadone. The study showed that there were 0.137 methadone-related deaths per 1,000 prescriptions of methadone, versus 0.022 deaths per 1,000 for buprenorphine-based drugs. However, the study did include naloxone-containing buprenorphine drugs in the data.
Subutex Overdose Amount
The dose that will produce overdose depends on a number of individual factors, including:
- Route of Administration: Intravenous administration can produce overdose at relatively low doses. Subutex is not available as an intravenous drug, so it must be prepared for IV ingestion by the person using it.
- Use of Other Sedatives: Other central nervous system depressants (such as alcohol, sedatives or benzodiazepines) greatly lower the dose of Subutex needed to cause an overdose.
- Opioid Tolerance: People who are not habitual users of opioids (and therefore have no opioid tolerance) may overdose on the doses that are used to treat opioid-dependent individuals. Even a 2 mg sublingual dose of Subutex can kill an opioid-naïve individual.
- Underlying Health: Poor health or the presence of underlying breathing problems may lower the fatal dose of Subutex.
- Liver Function: Impaired liver function can lower the fatal dose.
An individual’s age, weight and gender can also play a role in their likelihood of overdosing on Subutex.
Subutex Overdose Symptoms
Acute overdose with Subutex produces classic opioid overdose symptoms, such as:
- Pinpoint pupils
- Sedation, loss of consciousness or coma
- Low blood pressure
- Respiratory suppression (weak, shallow breathing or not breathing at all)
The U.S. Substance Abuse and Mental Health Services Administration (SAMHSA) has a downloadable Opioid Overdose Prevention Toolkit, which suggests that people should suspect overdose if they see the following signs:
- Pale or clammy face
- Limp body
- A bluish tint to fingernails or lips
- Vomiting or gurgling noises
- Cannot be awakened or cannot speak
- Slowed or stopped breathing
- Slowed or stopped heartbeat
Subutex Overdose Prevention
The greatest measures to prevent Subutex overdoses are ensuring that the medication is taken as prescribed and not given to someone who does not have a prescription. In efforts to prevent drug diversion, doctors require a special license and clearance from the DEA to prescribe Subutex. While that probably does help prevent prescription diversion, it also makes Subutex more difficult to obtain than fentanyl or heroin. As such, there may be future changes to controls overprescribing Subutex.
The SAMHSA Opioid Overdose Prevention Toolkit makes recommendations for preventing Subutex and other opioid overdoses through the following instructions:
- Take Subutex as prescribed; do not take more medication or take it more often than instructed
- Do not take medication that was not prescribed for you
- Never mix Subutex with alcohol, sedatives or illicit substances
- Store Subutex safely where children or pets can’t reach it
- Dispose of unused medications promptly and properly
- Learn the signs of overdose and how to use naloxone
- Teach your family members and friends how to respond to an overdose
Subutex Overdose Treatment
When Subutex overdose does occur, treating it can be especially problematic. First of all, Subutex has an unusually long half-life (31–35 hours), so an anti-overdose drug (either naltrexone or naloxone) must often be administered repeatedly until the drug wears off.
Subutex has a much stronger affinity for opioid receptors than naltrexone and naloxone. That means that these drugs are much less effective at reversing overdose for Subutex than for any other opioid, so unusually high doses of these anti-overdose drugs are usually required.
Because of these two factors, people who overdose on Subutex require emergency medical support of their breathing and heart functions and other supportive measures until the drug’s effects wear off.
The SAMHSA Opioid Overdose Prevention Toolkit has advice for first responders, including “do’s and don’ts” and the five essential steps:
- Step 1: Evaluate for signs of opioid overdose
- Step 2: Call 911 for help
- Step 3: Administer naloxone
- Step 4: Support the person’s breathing
- Step 5: Monitor the person’s response
Subutex overdose is highly unlikely in people who take the drug as prescribed for them. For people who are abusing the drug, particularly those who attempt to use it intravenously or combine the drug with other sedating drugs, overdose is a significant risk. If you have concerns about Subutex or any other drug abuse in yourself or a loved one, there is help available. Please feel free to contact us at The Recovery Village Ridgefield for a confidential discussion with one of our staff.
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Centers for Disease Control and Prevention (CDC). “2018 annual surveillance report of drug-related risks and outcomes: United States.” August 31, 2018. Accessed August 3, 2019.
Chu, Rebecca, et al. “Opioid agonists, partial agonists, antagonists: Oh my!” January 6, 2018. Accessed August 3, 2019.
Cleary, Pratt, et al. “A brief review of buprenorphine products.” Pharmacy Times, March 22, 2016. Accessed August 3, 2019.
Food and Drug Administration (FDA). “Highlights of prescribing information: Subutex (buprenorphine) sublingual tablet.” December 2016. Accessed August 3, 2019.
Marteau, Dave, et al. “The relative risk of fatal poisoning by methadone or buprenorphine within the wider population of England and Wales.” British Medical Journal Open, May 29, 2015. Accessed August 3, 2019.
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Substance Abuse and Mental Health Administration (SAMHSA). “National Survey on Drug Use and Health 2017.” September 2018. Accessed August 3, 2019.
Substance Abuse and Mental Health Administration (SAMHSA). “Opioid overdose prevention toolkit.” 2018. Accessed August 3, 2019.
Wakeman, Sarah, et al. “Primary care and the opioid-overdose crisis – Buprenorphine myths and realities.” The New England Journal of Medicine, July 5, 2018. Accessed August 3, 2019.
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Medical Disclaimer: The Recovery Village aims to improve the quality of life for people struggling with a substance use or mental health disorder with fact-based content about the nature of behavioral health conditions, treatment options and their related outcomes. We publish material that is researched, cited, edited and reviewed by licensed medical professionals. The information we provide is not intended to be a substitute for professional medical advice, diagnosis or treatment. It should not be used in place of the advice of your physician or other qualified healthcare provider.