Suboxone Overdose – Risk Factors, Signs & Symptoms

Suboxone is a brand-name drug used for opioid-replacement therapy (medication-assisted treatment) in treating opioid use disorder. It contains the opioid buprenorphine and the opioid-blocker naloxone in a 4-to-1 ratio. Suboxone is a sublingual (dissolved under the tongue) film strip, while sublingual tablets with the same active ingredients are available under the brand name Zubsolv. Suboxone is the most commonly prescribed formulation of buprenorphine and naloxone for opioid use disorder.

While Suboxone is proven safe and effective for treating opioid use disorder, it is still potentially dangerous if misused and should be treated carefully. 

Can You Overdose on Suboxone?

Yes. Suboxone overdose is possible and is especially likely in two circumstances:

• When it is taken with other sedatives or drugs 
• When it is taken by someone who does not habitually use opioids (i.e., who has no opioid tolerance)

Suboxone has many safeguards against overdose. It contains the opioid antagonist (blocker) naloxone to help block misuse and overdose when the drug is injected. Naloxone quickly deactivates when taken orally (including sublingually) and has less receptor affinity than buprenorphine and a short half-life, so it is not a guarantee against overdose, especially when the overdose occurs after the drug is taken by mouth.

Buprenorphine has unique pharmacological properties that make overdose unlikely, including:

• Ceiling effect: Respiratory suppression reaches a peak that doesn’t increase when more of the drug is taken.
• Partial opioid agonist: Buprenorphine binds to opioid receptors in the brain but has less activity at these receptors than other opioids, so it has a lower risk of respiratory suppression (the main cause of death in opioid overdose) than other opioids.
• Poor oral absorption: Suboxone swallowed inadvertently has limited absorption from the gut, making overdose less likely. Instead, the drug readily absorbs from the mucus membranes in the mouth.

How Much Suboxone Causes an Overdose?

The dose of Suboxone that would cause an overdose depends on several factors specific to the individual taking the drug. In opioid-naïve people, overdose has been reported with even a 2 mg sublingual dose, the lowest available dose.

The dose that will produce an overdose depends on several individual factors:

• Route of administration: Intravenous administration produces overdose at much lower doses than other forms of administration due to the presence of naloxone.
• Use of other sedatives: Other central nervous system depressants (such as mixing with alcohol, sedatives, tricyclic antidepressants, barbiturates or benzodiazepines) greatly lower the dose needed to produce an overdose.
• The individual’s tolerance of opioids: People who do not use opioids habitually (and therefore have no opioid tolerance) may overdose on the doses used to treat opioid-dependent individuals.
• The individual’s underlying health: Poor health or underlying breathing problems may lower the fatal dose.
• Individual factors: A person’s age, weight and gender can impact the amount of Suboxone it takes to induce an overdose.

Suboxone Overdose Risk Factors

Suboxone overdose can occur when individuals try to misuse Suboxone or other drugs. The half-life of buprenorphine — the opioid in Suboxone — is very long (3–35 hours), while the half-life of naloxone — the opioid blocker — is very short (30–90 minutes).

A dangerous scenario occurs when someone takes a lot of Suboxone to try to get high or takes very high doses of another opioid in an attempt to overcome the blocking effects of Suboxone. Then, when the naloxone wears, the opioids may suddenly be at a lethal level.

The most common scenario for Suboxone overdose is when the drug is combined with other sedating drugs, especially benzodiazepines or other depressants. 

Suboxone Overdose Signs & Symptoms

Suboxone overdose symptoms are the same as expected from any other opioid overdose and may include:

• Pinpoint pupils
• Sedation, loss of consciousness, coma
• Low blood pressure, shock
• Respiratory suppression (weak, shallow breathing or not breathing at all)
• Death

The U.S. Substance Abuse and Mental Health Services Administration’s (SAMHSA) downloadable Opioid Overdose Prevention Toolkit suggests that people should suspect overdose if they see the following signs:

• Pale and/or clammy face
• Limp body
• Bluish fingernails and/or lips 
• Vomiting or gurgling noises
• Inability to speak
• Inability to wake up
• Slow or stopped breathing
• Slow or stopped heartbeat

Is Suboxone Overdose Fatal?

Suboxone overdose death is uncommon, which is likely why the CDC does not track Suboxone (or any other buprenorphine product) deaths in its opioid overdose fatality reports. The drug is not contained in standard drug screening panels used in hospitals and by medical examiners, so data on its role in hospital visits and deaths is unlikely to be available until that changes. However, The New York Times reported in 2013 that there had been 420 deaths in America where buprenorphine was the “primary suspect” since the drug was first introduced in 2003. 

One large study from the U.K. showed that buprenorphine-containing drugs are six times less likely to cause overdose than methadone. The study showed 0.137 methadone-related deaths per 1,000 prescriptions of methadone vs. 0.022 deaths per 1,000 for buprenorphine-based drugs.

The major risk of overdose is when Suboxone is taken by people who are opioid naïve. Although buprenorphine is the most abused prescription opioid in America, one study found that 74% of people who use diverted Suboxone do so to self-treat their opioid withdrawal, mostly because they cannot afford to obtain it by prescription.

Suboxone Overdose Treatment

Treating Suboxone overdose can be especially problematic. Because of buprenorphine’s unusually long half-life, an anti-overdose drug (naltrexone or naloxone) must often be administered repeatedly until the drug wears off.

Buprenorphine has a much stronger affinity for opioid receptors than naltrexone and naloxone. Therefore, Narcan for Suboxone overdose (or another naloxone or naltrexone product) is much less effective at reversing overdose for Suboxone 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 Suboxone need emergency medical support 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 one: Evaluate for signs of opioid overdose
• Step two: Call 911 for help
• Step three: Administer naloxone
• Step four: Support the person’s breathing
• Step five: Monitor the person’s response

Suboxone Drug Overdose Prevention

The SAMHSA Opioid Overdose Prevention Toolkit makes recommendations to prevent overdosing on Suboxone or other opioids, including the following instructions:

• Take Suboxone as prescribed; do not take more or take it more often than instructed.
• Do not take medication that was not prescribed for you.
• Never mix Suboxone with alcohol, sedatives or illicit substances.
• Store Suboxone 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.

Suboxone overdose is highly unlikely in people who take the drug as prescribed. Attempts at abusing the drug or diverting it can lead to overdose. If you have concerns about Suboxone or any other drug misuse in yourself or a loved one, help is available. Contact The Recovery Village Ridgefield for a confidential discussion about treatment options.