"Hospital emergency department visits related to the use of the illicit drug methamphetamine rose from 67,954 in 2007 to 102,961 in 2011 according to a report by the Substance Abuse and Mental Health Services Administration (SAMHSA).
SUBOXONE sublingual tablet is indicated for the maintenance treatment of opioid dependence and should be used as part of a complete treatment plan to include counseling and psychosocial support. Under the Drug Addiction Treatment Act (DATA) codified at 21 U.S.C. 823(g), prescription use of this product in the treatment of opioid dependence is limited to physicians who meet certain qualifying requirements, and who have notified the Secretary of Health and Human Services (HHS) of their intent to prescribe this product for the treatment of opioid dependence and have been assigned a unique identification number that must be included on every prescription.
DOSAGE AND ADMINISTRATION
SUBOXONE sublingual tablet is administered sublingually as a single daily dose. SUBOXONE sublingual tablets should be used in patients who have been initially inducted using SUBUTEX® (buprenorphine) sublingual tablets.
Medication should be prescribed in consideration of the frequency of visits. Provision of multiple refills is not advised early in treatment or without appropriate patient follow-up visits.
- SUBOXONE sublingual tablet is indicated for maintenance treatment. The recommended target dosage of SUBOXONE sublingual tablet is 16/4 mg buprenorphine/naloxone/day as a single daily dose
- The dosage of SUBOXONE sublingual tablet should be progressively adjusted in increments/decrements of 2/0.5 mg or 4/1 mg buprenorphine/naloxone to a level that holds the patient in treatment and suppresses opioid withdrawal signs and symptoms
- The maintenance dose of SUBOXONE sublingual tablet is generally in the range of 4/1 mg buprenorphine/naloxone to 24/6 mg buprenorphine/naloxone per day depending on the individual patient. Dosages higher than this have not been demonstrated to provide any clinical advantage
Method Of Administration
SUBOXONE sublingual tablet should be placed under the tongue until it is dissolved. For doses requiring the use of more than two tablets, patients are advised to either place all the tablets at once or alternatively (if they cannot fit in more than two tablets comfortably), place two tablets at a time under the tongue. Either way, the patients should continue to hold the tablets under the tongue until they dissolve; swallowing the tablets reduces the bioavailability of the drug. To ensure consistency in bioavailability, patients should follow the same manner of dosing with continued use of the product.
Proper administration technique should be demonstrated to the patient.
Treatment should be initiated with supervised administration, progressing to unsupervised administration as the patient's clinical stability permits. SUBOXONE sublingual tablet is subject to diversion and abuse. When determining the prescription quantity for unsupervised administration, consider the patient's level of stability, the security of his or her home situation, and other factors likely to affect the ability to manage supplies of take-home medication.
Ideally patients should be seen at reasonable intervals (e.g., at least weekly during the first month of treatment) based upon the individual circumstances of the patient. Medication should be prescribed in consideration of the frequency of visits. Provision of multiple refills is not advised early in treatment or without appropriate patient follow-up visits. Periodic assessment is necessary to determine compliance with the dosing regimen, effectiveness of the treatment plan, and overall patient progress.
Once a stable dosage has been achieved and patient assessment (e.g., urine drug screening) does not indicate illicit drug use, less frequent follow-up visits may be appropriate. A once-monthly visit schedule may be reasonable for patients on a stable dosage of medication who are making progress toward their treatment objectives. Continuation or modification of pharmacotherapy should be based on the physician's evaluation of treatment outcomes and objectives such as:
- Absence of medication toxicity
- Absence of medical or behavioral adverse effects
- Responsible handling of medications by the patient
- Patient's compliance with all elements of the treatment plan (including recovery-oriented activities, psychotherapy, and/or other psychosocial modalities)
- Abstinence from illicit drug use (including problematic alcohol and/or benzodiazepine use)
If treatment goals are not being achieved, the physician should re-evaluate the appropriateness of continuing the current treatment.
Physicians will need to decide when they cannot appropriately provide further management for particular patients. For example, some patients may be abusing or dependent on various drugs, or unresponsive to psychosocial intervention such that the physician does not feel that he/she has the expertise to manage the patient. In such cases, the physician may want to assess whether to refer the patient to a specialist or more intensive behavioral treatment environment. Decisions should be based on a treatment plan established and agreed upon with the patient at the beginning of treatment.
Patients who continue to misuse, abuse, or divert buprenorphine products or other opioids should be provided with, or referred to, more intensive and structured treatment.
Patients With Hepatic Impairment
Because the doses of this fixed combination product cannot be individually titrated, severe hepatic impairment results in a reduced clearance of naloxone to a much greater extent than buprenorphine, and moderate hepatic impairment also results in a reduced clearance of naloxone to a greater extent than buprenorphine, the combination product should generally be avoided in patients with severe hepatic impairment and may not be appropriate for patients with moderate hepatic impairment [see WARNINGS AND PRECAUTIONS].
The decision to discontinue therapy with SUBOXONE sublingual tablets after a period of maintenance should be made as part of a comprehensive treatment plan. Both gradual and abrupt discontinuation of buprenorphine has been used, but the data are insufficient to determine the best method of dose taper at the end of treatment.
Switching Between SUBOXONE (Buprenorphine And Naloxone) Sublingual Film And SUBOXONE Sublingual Tablets
Patients being switched between SUBOXONE (buprenorphine and naloxone) sublingual tablets and SUBOXONE sublingual film should be started on the same dosage as the previously administered product. However, dosage adjustments may be necessary when switching between products. Because of the potentially greater relative bioavailability of SUBOXONE sublingual film compared to SUBOXONE (buprenorphine and naloxone) sublingual tablets, patients switching from SUBOXONE (buprenorphine and naloxone) sublingual tablets to SUBOXONE sublingual film should be monitored for over-medication. Those switching from SUBOXONE sublingual film to SUBOXONE (buprenorphine and naloxone) sublingual tablets should be monitored for withdrawal or other indications of under-dosing. In clinical studies, pharmacokinetics of SUBOXONE sublingual film was similar to the respective dosage strengths of SUBOXONE (buprenorphine and naloxone) sublingual tablets, although not all doses and dose combinations met bioequivalence criteria.
Dosage Forms And Strengths
SUBOXONE sublingual tablet is supplied as an uncoated hexagonal orange tablet in two dosage strengths:
- buprenorphine/naloxone 2 mg/0.5 mg, and
- buprenorphine/naloxone 8 mg/2 mg
Storage And Handling
SUBOXONE sublingual tablet is an uncoated hexagonal orange tablet, imprinted with a sword logo on one side and an alphanumeric imprint identifying the product and strength on the other side, supplied in white HDPE bottles:
NDC 12496-1283-2 (buprenorphine and naloxone 2 mg/0.5 mg/sublingual tablet; content expressed in terms of free base) - 30 tablets per bottle
NDC 12496-1306-2 (buprenorphine and naloxone 8 mg/2 mg/sublingual tablet; content expressed in terms of free base) - 30 tablets per bottle
Store at 25°C (77°F), excursions permitted to 15-30°C (59-86°F) [see USP Controlled Room Temperature]
Patients should be advised to store buprenorphine-containing medications safely and out of sight and reach of children. Destroy any unused medication appropriately [see Disposal of Unused SUBOXONE Sublingual Tablets].
Manufactured by: Reckitt Benckiser Healthcare (UK) Ltd., Hull, HU8 7DS. UK. Distributed by: Reckitt Benckiser Pharmaceuticals Inc., Richmond, VA 23235. Revised: December 2014
Last reviewed on RxList: 3/4/2015
This monograph has been modified to include the generic and brand name in many instances.
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