Buprenorphine (mucous membrane)

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# Overview
Buprenorphine (mucous membrane) is an opioid analgesic that is FDA approved for the treatment of chronic, severe pain in patients requiring long-term daily around-the-clock opioid analgesic.   Common adverse reactions include application site erythema, application site irritation, application site rash, pruritus, constipation, nausea, vomiting, xerostomia, dizziness, headache, and somnolence.

# Adult Indications and Dosage

## FDA-Labeled Indications and Dosage (Adult)
- Prior to initiating, discontinue all other around-the-clock opioid drugs.
- Pain, chronic (severe), in patients requiring long-term daily around-the-clock opioid analgesic: individualize dose; initial dose selection must take into account patient's prior analgesic treatment experience and risk factors for addiction, abuse, and misuse; use of 10, 15, and 20 mcg/hr strengths is restricted to opioid-tolerant patients only
- Pain, chronic (severe), in patients requiring long-term daily around-the-clock opioid analgesic: (as first opioid) initial, 5 mcg/hr transdermally; titrate based on analgesic requirement and tolerance at a minimum interval of every 72 hours; replace patch every 7 days; max 20 mcg/hr.
- Pain, chronic (severe), in patients requiring long-term daily around-the-clock opioid analgesic: (prior total daily dose of opioids less than 30 mg of oral morphine equivalents per day) discontinue around-the-clock opioid drugs; initiate 5 mcg/hr transdermally at next dosing interval; replace patch every 7 days; titrate based on analgesic requirement and tolerance at a minimum interval of every 72 hours; max 20 mcg/hr.
- Pain, chronic (severe), in patients requiring long-term daily around-the-clock opioid analgesic: (prior total daily dose of opioids between 30 and 80 mg of oral morphine equivalents per day) taper previous around-the-clock opioids for up to 7 days to no more than 30 mg of oral morphine equivalents per day; then discontinue around-the-clock opioid drugs and initiate 10 mcg/hr TRANSDERMALLY at next dosing interval; replace patch every 7 days; titrate based on analgesic requirement and tolerance at a minimum interval of every 72 hours; max 20 mcg/hr; short-acting analgesics may be used as needed until efficacy is attained
- Pain, chronic (severe), in patients requiring long-term daily around-the-clock opioid analgesic: (total daily dose of opioids greater than 80 mg of oral morphine equivalents per day) consider an alternative analgesic as buprenorphine 20 mcg/hr may not provide adequate analgesia

## Off-Label Use and Dosage (Adult)

### Guideline-Supported Use
There is limited information about Off-Label Guideline-Supported Use of Buprenorphine in adult patients.

### NonGuideline-Supported Use
There is limited information about Off-Label NonGuideline-Supported Use of Buprenorphine in adult patients.

# Pediatric Indications and Dosage

## FDA-Labeled Indications and Dosage (Pediatric)
There is limited information about safety and efficacy of buprenorphine transdermal have not been established in patients younger than 18 years.

## Off-Label Use and Dosage (Pediatric)

### Guideline-Supported Use
There is limited information about Off-Label Guideline-Supported Use of Buprenorphine in pediatric patients.

### NonGuideline-Supported Use
There is limited information about Off-Label NonGuideline-Supported Use of Buprenorphine in pediatric patients.

# Contraindications
- Buprenorphine sublingual tablet should not be administered to patients who have been shown to be hypersensitive to buprenorphine or naloxone as serious adverse reactions, including anaphylactic shock, have been reported.

# Warnings
- Buprenorphine can be abused in a manner similar to other opioids, legal or illicit. Prescribe and dispense buprenorphine with appropriate precautions to minimize risk of misuse, abuse, or diversion, and ensure appropriate protection from theft, including in the home. Clinical monitoring appropriate to the patient's level of stability is essential. Multiple refills should not be prescribed early in treatment or without appropriate patient follow-up visits.
- Buprenorphine, particularly when taken by the IV route, in combination with benzodiazepines or other CNS depressants (including alcohol), has been associated with significant respiratory depression and death. Many, but not all, post-marketing reports regarding coma and death associated with the concomitant use of buprenorphine and benzodiazepines involved misuse by self-injection. Deaths have also been reported in association with concomitant administration of buprenorphine with other depressants such as alcohol or other CNS depressant drugs. Patients should be warned of the potential danger of self-administration of benzodiazepines or other depressants while under treatment with buprenorphine sublingual tablets.
- In the case of overdose, the primary management should be the re-establishment of adequate ventilation with mechanical assistance of respiration, if required. Naloxone may be of value for the management of buprenorphine overdose. Higher than normal doses and repeated administration may be necessary.
- Buprenorphine sublingual tablets should be used with caution in patients with compromised respiratory function (e.g., chronic obstructive pulmonary disease, cor pulmonale, decreased respiratory reserve, hypoxia, hypercapnia, or pre-existing respiratory depression).
- Patients receiving buprenorphine in the presence of opioid analgesics, general anesthetics, benzodiazepines, phenothiazines, other tranquilizers, sedative/hypnotics, or other CNS depressants (including alcohol) may exhibit increased CNS depression. Consider dose reduction of CNS depressants, buprenorphine sublingual tablets, or both in situations of concomitant prescription.
- Buprenorphine can cause fatal respiratory depression in children who are accidentally exposed to it. Store buprenorphine containing medications safely out of the sight and reach of children and destroy any unused medication appropriately.
- Buprenorphine is a partial agonist at the mu-opioid receptor and chronic administration produces physical dependence of the opioid type, characterized by withdrawal signs and symptoms upon abrupt discontinuation or rapid taper. The withdrawal syndrome is typically milder than seen with full agonists and may be delayed in onset. Buprenorphine can be abused in a manner similar to other opioids. This should be considered when prescribing or dispensing buprenorphine in situations when the clinician is concerned about an increased risk of misuse, abuse, or diversion.
- Cases of cytolytic hepatitis and hepatitis with jaundice have been observed in individuals receiving buprenorphine in clinical trials and through post-marketing adverse event reports. The spectrum of abnormalities ranges from transient asymptomatic elevations in hepatic transaminases to case reports of death, hepatic failure, hepatic necrosis, hepatorenal syndrome, and hepatic encephalopathy. In many cases, the presence of pre-existing liver enzyme abnormalities, infection with hepatitis B or hepatitis C virus, concomitant usage of other potentially hepatotoxic drugs, and ongoing injecting drug use may have played a causative or contributory role. In other cases, insufficient data were available to determine the etiology of the abnormality. Withdrawal of buprenorphine has resulted in amelioration of acute hepatitis in some cases; however, in other cases no dose reduction was necessary. The possibility exists that buprenorphine had a causative or contributory role in the development of the hepatic abnormality in some cases. Liver function tests, prior to initiation of treatment is recommended to establish a baseline. Periodic monitoring of liver function during treatment is also recommended. A biological and etiological evaluation is recommended when a hepatic event is suspected. Depending on the case, buprenorphine sublingual tablet may need to be carefully discontinued to prevent withdrawal signs and symptoms and a return by the patient to illicit drug use, and strict monitoring of the patient should be initiated.
- Cases of hypersensitivity to buprenorphine and naloxone containing products have been reported both in clinical trials and in the post-marketing experience. cases of bronchospasm, angioneurotic edema, and anaphylactic shock have been reported. the most common signs and symptoms include rashes, hives, and pruritus. a history of hypersensitivity to buprenorphine or naloxone is a contraindication to the use of buprenorphine sublingual tablet.
- Because it contains naloxone, buprenorphine msublingual tablet is likely to produce withdrawal signs and symptoms if misused parenterally by individuals dependent on full opioid agonists such as heroin, morphine, or methadone. Because of the partial agonist properties of buprenorphine, buprenorphine sublingual tablet may precipitate opioid withdrawal signs and symptoms in such persons if administered sublingually before the agonist effects of the opioid have subsided.
- Neonatal abstinence syndrome has been reported in the infants of women treated with buprenorphine during pregnancy. From post-marketing reports, the time to onset of neonatal withdrawal signs ranged from Day 1 to Day 8 of life with most cases occurring on Day 1. Adverse events associated with the neonatal abstinence syndrome included hypertonia, neonatal tremor, neonatal agitation, and myoclonus, and there have been reports of convulsions, apnea, respiratory depression, and bradycardia.
- There have been reported deaths of opioid naive individuals who received a 2 mg dose of buprenorphine as a sublingual tablet for analgesia. buprenorphine sublingual tablet is not appropriate as an analgesic.
- Buprenorphine sublingual tablet may impair the mental or physical abilities required for the performance of potentially dangerous tasks such as driving a car or operating machinery, especially during treatment induction and dose adjustment. Patients should be cautioned about driving or operating hazardous machinery until they are reasonably certain that buprenorphine sublingual tablet therapy does not adversely affect his or her ability to engage in such activities.
- Like other opioids, buprenorphine sublingual tablets may produce orthostatic hypotension in ambulatory patients.
- Buprenorphine, like other opioids, may elevate cerebrospinal fluid pressure and should be used with caution in patients with head injury, intracranial lesions, and other circumstances when cerebrospinal pressure may be increased. Buprenorphine can produce miosis and changes in the level of consciousness that may interfere with patient evaluation.
- Buprenorphine has been shown to increase intracholedochal pressure, as do other opioids, and thus should be administered with caution to patients with dysfunction of the biliary tract.
- As with other opioids, buprenorphine may obscure the diagnosis or clinical course of patients with acute abdominal conditions.
- Buprenorphine sublingual tablet should be administered with caution in debilitated patients and those with myxedema or hypothyroidism, adrenal cortical insufficiency (e.g., Addison's disease); CNS depression or coma; toxic psychoses; prostatic hypertrophy or urethral stricture; acute alcoholism; delirium tremens; or kyphoscoliosis.

# Adverse Reactions

## Clinical Trials Experience
- Because clinical trials are conducted under widely varying conditions, adverse reaction rates observed in the clinical trials of a drug cannot be directly compared to rates in the clinical trials of another drug and may not reflect the rates observed in practice.
- The safety of buprenorphine/naloxone was evaluated in 497 opioid-dependent subjects. The prospective evaluation of buprenorphine/naloxone was supported by clinical trials using buprenorphine tablets without naloxone and other trials using buprenorphine sublingual solutions. In total, safety data were available from 3214 opioid-dependent subjects exposed to buprenorphine at doses in the range used in treatment of opioid addiction.

## Postmarketing Experience
- The following adverse reactions have been identified during post-approval use of buprenorphine and naloxone sublingual tablets. Because these reactions are reported voluntarily from a population of uncertain size, it is not always possible to reliably estimate a causal relationship to drug exposure.
- The most frequently reported post-marketing adverse event not observed in clinical trials was peripheral edema.

# Drug Interactions
- Buprenorphine is metabolized to norbuprenorphine primarily by cytochrome CYP3A4; therefore, potential interactions may occur when buprenorphine sublingual tablets is given concurrently with agents that affect CYP3A4 activity. The concomitant use of buprenorphine sublingual tablet with CYP3A4 inhibitors (e.g., azole antifungals such as ketoconazole, macrolide antibiotics such as erythromycin, and HIV protease inhibitors) should be monitored and may require dose-reduction of one or both agents.
- The interaction of buprenorphine with CYP3A4 inducers has not been studied; therefore, it is recommended that patients receiving buprenorphine sublingual tablets be monitored for signs and symptoms of opioid withdrawal if inducers of CYP3A4 (e.g., efavirenz, phenobarbital, carbamazepine, phenytoin, rifampicin) are co-administered.
- Three classes of antiretroviral agents have been evaluated for CYP3A4 interactions with buprenorphine. Nucleoside reverse transcriptase inhibitors (NRTIs) do not appear to induce or inhibit the P450 enzyme pathway, thus no interactions with buprenorphine are expected. Non-nucleoside reverse transcriptase inhibitors (NNRTIs) are metabolized principally by CYP3A4. Efavirenz, nevirapine and etravirine are known CYP3A inducers whereas delaviridine is a CYP3A inhibitor. Significant pharmacokinetic interactions between NNRTIs (e.g., efavirenz and delavirdine) and buprenorphine have been shown in clinical studies, but these pharmacokinetic interactions did not result in any significant pharmacodynamic effects. It is recommended that patients who are on chronic buprenorphine treatment have their dose monitored if NNRTIs are added to their treatment regimen. Studies have shown some antiretroviral protease inhibitors (PIs) with CYP3A4 inhibitory activity (nelfinavir, lopinavir/ritonavir, ritonavir) have little effect on buprenorphine pharmacokinetic and no significant pharmacodynamic effects. Other PIs with CYP3A4 inhibitory activity (atazanavir and atazanavir/ritonavir) resulted in elevated levels of buprenorphine and norbuprenorphine and patients in one study reported increased sedation. Symptoms of opioid excess have been found in post-marketing reports of patients receiving buprenorphine and atazanavir with and without ritonavir concomitantly. Monitoring of patients taking buprenorphine and atazanavir with and without ritonavir is recommended, and dose reduction of buprenorphine may be warranted.
- There have been a number of post-marketing reports regarding coma and death associated with the concomitant use of buprenorphine and benzodiazepines. In many, but not all of these cases, buprenorphine was misused by self-injection. Preclinical studies have shown that the combination of benzodiazepines and buprenorphine altered the usual ceiling effect on buprenorphine-induced respiratory depression, making the respiratory effects of buprenorphine appear similar to those of full opioid agonists. Buprenorphine sublingual tablets should be prescribed with caution to patients taking benzodiazepines or other drugs that act on the CNS, regardless of whether these drugs are taken on the advice of a physician or are being abused/misused. Patients should be warned that it is extremely dangerous to self-administer non-prescribed benzodiazepines while taking buprenorphine sublingual tablets, and should also be cautioned to use benzodiazepines concurrently with buprenorphine sublingual tablets only as directed by their physician.

# Use in Specific Populations

### Pregnancy
Pregnancy Category (FDA): C
- There are no adequate and well-controlled studies of buprenorphine sublingual tablets or buprenorphine/naloxone in pregnant women. . Limited published data on use of buprenorphine, the active ingredient in buprenorphine, in pregnancy, have not shown an increased risk of major malformations. All pregnancies, regardless of drug exposure, have a background risk of 2-4% for major birth defects, and 15-20% for pregnancy loss. Reproductive and developmental studies in rats and rabbits identified adverse events at clinically relevant doses. Pre- and postnatal development studies in rats demonstrated dystocia, increased neonatal deaths, and developmental delays. No clear teratogenic effects were seen with a range of doses equivalent to or greater than the human dose. However, in a few studies, some events such as acephalus, omphalocele, and skeletal abnormalities were observed but these findings were not clearly treatment-related. Embryofetal death was also observed in both rats and rabbits.
- Buprenorphine sublingual tablets should be used during pregnancy only if the potential benefit justifies the potential risk to the fetus.
- Disease-associated maternal and embryo-fetal risk
- Opioid dependence in pregnancy is associated with adverse obstetrical outcomes such as low birth weight, preterm birth, and fetal death.
- Fetal/neonatal adverse reactions
- Neonatal abstinence syndrome may occur in newborn infants of mothers who were on buprenorphine maintenance treatment. Observe newborns for poor feeding, diarrhea, irritability, tremor, rigidity, and seizures, and manage accordingly.
Pregnancy Category (AUS): 
There is no Australian Drug Evaluation Committee (ADEC) guidance on usage of Buprenorphine (mucous membrane) in women who are pregnant.

### Labor and Delivery
- As with all opioids, use of buprenorphine prior to delivery may result in respiratory depression in the newborn. Closely monitor neonates for signs of respiratory depression. An opioid antagonist such as naloxone should be available for reversal of opioid induced respiratory depression in the neonate.
- Human Data
- Studies have been conducted to evaluate neonatal outcomes in women exposed to buprenorphine during pregnancy. Limited published data on malformations from trials, observational studies, case series, and case reports on buprenorphine use in pregnancy have not shown an increased risk of major malformations. Based on these studies the incidence of neonatal abstinence syndrome is not clear and there does not appear to be a dose-response relationship.
- Animal Data
- Buprenorphine has been shown to have differences in bioavailability compared to other buprenorphine/naloxone-containing sublingual products. The exposure margins listed below are based on body surface area comparisons (mg/m2) to the recommended human sublingual dose of 16 mg buprenorphine via Suboxone, which is equivalent to a human sublingual dose of 11.4 mg buprenorphine via Zubsolv.
- Effects on embryo-fetal development were studied in Sprague-Dawley rats and Russian white rabbits following oral (1:1) and intramuscular (IM) (3:2) administration of mixtures of buprenorphine and naloxone. Following oral administration to rats and rabbits, no teratogenic effects were observed at buprenorphine doses up to 250 mg/kg/day and 40 mg/kg/day, respectively (estimated exposure approximately 150 times and 50 times, respectively, the recommended human sublingual dose). No definitive drug-related teratogenic effects were observed in rats and rabbits at IM doses up to 30 mg/kg/day (estimated exposure approximately 20 times and 35 times, respectively, the recommended human sublingual dose). Acephalus was observed in one rabbit fetus from the low-dose group and omphalocele was observed in two rabbit fetuses from the same litter in the mid-dose group; no findings were observed in fetuses from the high-dose group. Following oral administration of buprenorphine to rats, dose-related post-implantation losses, evidenced by increases in the numbers of early resorptions with consequent reductions in the numbers of fetuses, were observed at doses of 10 mg/kg/day or greater (estimated exposure approximately 6 times the recommended human sublingual dose). In the rabbit, increased post-implantation losses occurred at an oral dose of 40 mg/kg/day. Following IM administration in the rat and the rabbit, post-implantation losses, as evidenced by decreases in live fetuses and increases in resorptions, occurred at 30 mg/kg/day. Buprenorphine was not teratogenic in rats or rabbits after IM or subcutaneous (SC) doses up to 5 mg/kg/day (estimated exposure was approximately 3 and 6 times, respectively, the recommended human sublingual dose), after IV doses up to 0.8 mg/kg/day (estimated exposure was approximately 0.5 times and equal to, respectively, the recommended human sublingual dose), or after oral doses up to 160 mg/kg/day in rats (estimated exposure was approximately 95 times the recommended human sublingual dose) and 25 mg/kg/day in rabbits (estimated exposure was approximately 30 times the recommended human sublingual dose). Significant increases in skeletal abnormalities (e.g., extra thoracic vertebra or thoraco-lumbar ribs) were noted in rats after SC administration of 1 mg/kg/day and up (estimated exposure was approximately 0.6 times the recommended human sublingual dose), but were not observed at oral doses up to 160 mg/kg/day. Increases in skeletal abnormalities in rabbits after IM administration of 5 mg/kg/day (estimated exposure was approximately 6 times the recommended human sublingual dose) or oral administration of 1 mg/kg/day or greater (estimated exposure was approximately equal to the recommended human sublingual dose) were not statistically significant.
- In rabbits, buprenorphine produced statistically significant pre-implantation losses at oral doses of 1 mg/kg/day or greater and post-implantation losses that were statistically significant at IV doses of 0.2 mg/kg/day or greater (estimated exposure approximately 0.3 times the recommended human sublingual dose).
- Dystocia was noted in pregnant rats treated intramuscularly with buprenorphine 5 mg/kg/day (approximately 3 times the recommended human sublingual dose). Fertility, peri-, and post-natal development studies with buprenorphine in rats indicated increases in neonatal mortality after oral doses of 0.8 mg/kg/day and up (approximately 0.5 times the recommended human sublingual dose), after IM doses of 0.5 mg/kg/day and up (approximately 0.3 times the recommended human sublingual dose), and after SC doses of 0.1 mg/kg/day and up (approximately 0.06 times the recommended human sublingual dose). An apparent lack of milk production during these studies likely contributed to the decreased pup viability and lactation indices. Delays in the occurrence of righting reflex and startle response were noted in rat pups at an oral dose of 80 mg/kg/day (approximately 50 times the recommended human sublingual dose).

### Nursing Mothers
- Based on two studies in 13 lactating women, buprenorphine and its metabolite norbuprenorphine are present in low levels in human milk and infant urine, and available data have not shown adverse reactions in breastfed infants . There are no data on the combination product buprenorphine/naloxone in breastfeeding , however oral absorption of naloxone is minimal. Caution should be exercised when Zubsolv is administered to a nursing woman. The developmental and health benefits of breastfeeding should be considered along with the mother's clinical need for Zubsolv and any potential adverse effects on the breastfed child from the drug or from the underlying maternal condition.
- Advise the nursing mother taking Zubsolv to monitor the infant for increased drowsiness and breathing difficulties.
- Data
- Based on limited data from a study of 6 lactating women who were taking a median oral dose of buprenorphine of 0.29 mg/kg/day 5-8 days after delivery, breast milk contained a median infant dose of 0.42 mcg/kg/day of buprenorphine and 0.33 mg/kg/day of norbuprenorphine, which are equal to 0.2% and 0.12% of the maternal weight-adjusted dose.
- Based on limited data from a study of 7 lactating women who were taking a median oral dose of buprenorphine of 7 mg/day an average of 1.12 months after delivery, the mean milk concentrations of buprenorphine and norbuprenorphine were 3.65 mcg/L and 1.94 mcg/L respectively. Based on the limited data from this study, and assuming milk consumption of 150 mL/kg/day, an exclusively breastfed infant would receive an estimated mean of 0.55 mcg/kg/day of buprenorphine and 0.29 mcg/kg/day of norbuprenorphine, which are 0.38% and 0.18% of the maternal weight-adjusted dose.
- No adverse reactions were observed in the infants in these two studies.

### Pediatric Use
- The safety and effectiveness of buprenorphine sublingual tablets have not been established in pediatric patients. This product is not appropriate for the treatment of neonatal abstinence syndrome in neonates, because it contains naloxone, an opioid antagonist.

### Geriatic Use
- Clinical studies of buprenorphine/naloxone sublingual tablets did not include sufficient numbers of subjects aged 65 and over to determine whether they responded differently than younger subjects. Other reported clinical experience has not identified differences in responses between the elderly and younger patients. In general, dose selection for an elderly patient should be cautious, usually starting at the low end of the dosing range, reflecting the greater frequency of decreased hepatic, renal, or cardiac function, and of concomitant disease or other drug therapy.

### Gender
There is no FDA guidance on the use of Buprenorphine (mucous membrane) with respect to specific gender populations.

### Race
There is no FDA guidance on the use of Buprenorphine (mucous membrane) with respect to specific racial populations.

### Renal Impairment
- No differences in buprenorphine pharmacokinetics were observed between 9 dialysis-dependent and 6 normal patients following IV administration of 0.3 mg buprenorphine. The effects of renal failure on naloxone pharmacokinetics are unknown.

### Hepatic Impairment
- The effect of hepatic impairment on the pharmacokinetics of buprenorphine and naloxone is unknown. Since both drugs are extensively metabolized, the plasma levels will be expected to be higher in patients with moderate and severe hepatic impairment. However, it is not known whether both drugs are affected to the same degree. Therefore, dosage should be adjusted and patients should be watched for signs and symptoms of precipitated opioid withdrawal.

### Females of Reproductive Potential and Males
There is no FDA guidance on the use of Buprenorphine (mucous membrane) in women of reproductive potentials and males.

### Immunocompromised Patients
There is no FDA guidance one the use of Buprenorphine (mucous membrane) in patients who are immunocompromised.

# Administration and Monitoring

### Administration
- Do not cut, chew, or swallow buprenorphine sublingual tablets. ZUBSOLV sublingual tablet should be placed under the tongue until dissolved. The dissolve time for Zubsolv varies between individuals, and the median dissolve time observed was 5 minutes. For dosages requiring more than one sublingual tablet, place all tablets in different places under the tongue at the same time. Patients should keep the tablets under the tongue until dissolved; swallowing the tablets reduces the bioavailability of the drug. Advise patients not to eat or drink anything until the tablet is completely dissolved. To ensure consistency in bioavailability, patients should follow the same manner of dosing with continued use of the product.
- If a sequential mode of administration is preferred, patients should follow the same manner of dosing with continued use of the product, to ensure consistency in bioavailability.
- Proper administration technique should be demonstrated to the patient.

### Monitoring
There is limited information regarding Buprenorphine (mucous membrane) Monitoring in the drug label.

# IV Compatibility
There is limited information regarding the compatibility of Buprenorphine (mucous membrane) and IV administrations.

# Overdosage
- The manifestations of acute overdose include pinpoint pupils, sedation, hypotension, respiratory depression, and death.
- In the event of overdose, the respiratory and cardiac status of the patient should be monitored carefully. When respiratory or cardiac functions are depressed, primary attention should be given to the re-establishment of adequate respiratory exchange through provision of a patent airway and institution of assisted or controlled ventilation. Oxygen, IV fluids, vasopressors, and other supportive measures should be employed as indicated.
- In the case of overdose, the primary management should be the re-establishment of adequate ventilation with mechanical assistance of respiration, if required. Naloxone may be of value for the management of buprenorphine overdose. Higher than normal doses and repeated administration may be necessary. The long duration of action of ZUBSOLV should be taken into consideration when determining the length of treatment and medical surveillance needed to reverse the effects of an overdose. Insufficient duration of monitoring may put patients at risk.

# Pharmacology

## Mechanism of Action
- Buprenorphine sublingual tablet contains buprenorphine and naloxone. Buprenorphine is a partial agonist at the mu-opioid receptor and an antagonist at the kappa-opioid receptor. Naloxone is a potent antagonist at mu-opioid receptors and produces opioid withdrawal signs and symptoms, if administered parenterally, in individuals physically dependent on full opioid agonists.

## Structure
- ZUBSOLV (buprenorphine and naloxone) sublingual tablets are white menthol-flavored tablets in a triangular shape for the lower dosage strength (1.4 mg /0.36 mg) and a round shape for the higher dosage strength (5.7 mg/1.4 mg). They are debossed with the respective dosage strength of buprenorphine. They contain buprenorphine HCl, a mu-opioid receptor partial agonist and a kappa-opioid receptor antagonist, and naloxone HCl dihydrate, an opioid receptor antagonist, at a ratio of 4:1 (ratio of free bases). ZUBSOLV is intended for sublingual administration and is available in two dosage strengths, 1.4 mg buprenorphine with 0.36 mg naloxone and 5.7 mg buprenorphine with 1.4 mg naloxone. Each sublingual tablet also contains mannitol, citric acid, sodium citrate, microcrystalline cellulose, croscarmellose sodium, sucralose, menthol, silicon dioxide and sodium stearyl fumarate and menthol flavor.
- Chemically, buprenorphine HCl is (2S)-2--3,3-dimethylbutan-2-ol hydrochloride. It has the following chemical structure:
- Buprenorphine HCl has the molecular formula C29 H41 NO4 - HCl and the molecular weight is 504.10. It is a white or off-white crystalline powder, sparingly soluble in water, freely soluble in methanol, soluble in alcohol, and practically insoluble in cyclohexane.
- Chemically, naloxone HCl dihydrate is 17-Allyl-4,5-epoxy-3,14-dihydroxymorphinan-6-one hydrochloride dihydrate. It has the following chemical structure:
- Naloxone HCl dihydrate has the molecular formula C19H21NO4 - HCl - 2H20 and the molecular weight is 399.87. It is a white to slightly off-white powder and is freely soluble in water, soluble in alcohol, and practically insoluble in toluene and ether.

## Pharmacodynamics
- ZUBSOLV has been shown to have different bioavailability compared to SUBOXONE tablet. One ZUBSOLV 5.7 mg/1.4 mg tablet provides equivalent buprenorphine exposure and 12% lower naloxone exposure to one SUBOXONE 8 mg/2 mg tablet. The pharmacodynamic information of other currently marketed buprenorphine/naloxone-containing sublingual products is not directly comparable on a mg basis to ZUBSOLV.
- Comparisons of buprenorphine to full opioid agonists such as methadone and hydromorphone suggest that sublingual buprenorphine produces typical opioid agonist effects which are limited by a ceiling effect.
- In opioid-experienced subjects who were not physically dependent, acute sublingual doses of Suboxone tablets produced opioid agonist effects which reached a maximum between doses of 8/2 mg and 16/4 mg buprenorphine/naloxone.
- Opioid agonist ceiling-effects were also observed in a double-blind, parallel group, dose-ranging comparison of single doses of buprenorphine sublingual solution (1, 2, 4, 8, 16, or 32 mg), placebo and a full agonist control at various doses. The treatments were given in ascending dose order at intervals of at least one week to 16 opioid-experienced subjects who were not physically dependent. Both active drugs produced typical opioid agonist effects. For all measures for which the drugs produced an effect, buprenorphine produced a dose-related response. However, in each case, there was a dose that produced no further effect. In contrast, the highest dose of the full agonist control always produced the greatest effects. Agonist objective rating scores remained elevated for the higher doses of buprenorphine (8-32 mg) longer than for the lower doses and did not return to baseline until 48 hours after drug administration. The onset of effects appeared more rapidly with buprenorphine than with the full agonist control, with most doses nearing peak effect after 100 minutes for buprenorphine compared to 150 minutes for the full agonist control.
- Buprenorphine in IV (2, 4, 8, 12 and 16 mg) and sublingual (12 mg) doses has been administered to opioid-experienced subjects who were not physically dependent to examine cardiovascular, respiratory, and subjective effects at doses comparable to those used for treatment of opioid dependence. Compared to placebo, there were no statistically significant differences among any of the treatment conditions for blood pressure, heart rate, respiratory rate, O2 saturation, or skin temperature across time. Systolic BP was higher in the 8 mg group than placebo (3-hour AUC values). Minimum and maximum effects were similar across all treatments. Subjects remained responsive to low voice and responded to computer prompts. Some subjects showed irritability, but no other changes were observed.
- The respiratory effects of sublingual buprenorphine were compared with the effects of methadone in a double-blind, parallel group, dose ranging comparison of single doses of buprenorphine sublingual solution (1, 2, 4, 8, 16, or 32 mg) and oral methadone (15, 30, 45, or 60 mg) in non-dependent, opioid-experienced volunteers. In this study, hypoventilation not requiring medical intervention was reported more frequently after buprenorphine doses of 4 mg and higher than after methadone. Both drugs decreased O2 saturation to the same degree.
- Physiologic and subjective effects following acute sublingual administration of buprenorphine tablets and Suboxone tablets were similar at equivalent dose levels of buprenorphine. Naloxone had no clinically significant effect when administered by the sublingual route, although blood levels of the drug were measurable. Buprenorphine/naloxone, when administered sublingually to an opioid-dependent cohort, was recognized as an opioid agonist, whereas when administered intramuscularly, combinations of buprenorphine with naloxone produced opioid antagonist actions similar to naloxone. This finding suggests that the naloxone in buprenorphine/naloxone tablets may deter injection of buprenorphine/naloxone tablets by persons with active substantial heroin or other full mu-opioid dependence. However, clinicians should be aware that some opioid-dependent persons, particularly those with a low level of full mu-opioid physical dependence or those whose opioid physical dependence is predominantly to buprenorphine, abuse buprenorphine/naloxone combinations by the intravenous or intranasal route. In methadone-maintained patients and heroin-dependent subjects, IV administration of buprenorphine/naloxone combinations precipitated opioid withdrawal signs and symptoms and was perceived as unpleasant and dysphoric. In morphine-stabilized subjects, intravenously administered combinations of buprenorphine with naloxone produced opioid antagonist and withdrawal signs and symptoms that were ratio-dependent; the most intense withdrawal signs and symptoms were produced by 2:1 and 4:1 ratios, less intense by an 8:1 ratio.

## Pharmacokinetics
- Plasma levels of buprenorphine and naloxone increased with the sublingual dose of ZUBSOLV sublingual tablet. There was wide inter-patient variability in the sublingual absorption of buprenorphine and naloxone, but within subjects the variability was low. Both Cmax and AUC of buprenorphine increased with the increase in dose (in the range of 1.4 to 11.4 mg), although the increase was not directly dose-proportional. Naloxone did not affect the pharmacokinetics of buprenorphine.
- Buprenorphine has been shown to have different bioavailability compared to SUBOXONE tablet. One ZUBSOLV 5.7 mg/1.4 mg tablet provides equivalent buprenorphine exposure and 12% lower naloxone exposure to one SUBOXONE 8 mg/2 mg tablet.
- Buprenorphine is approximately 96% protein bound, primarily to alpha and beta globulin.
- Naloxone is approximately 45% protein bound, primarily to albumin.
- Buprenorphine undergoes both N-dealkylation to norbuprenorphine and glucuronidation. The N-dealkylation pathway is mediated primarily by the CYP3A4. Norbuprenorphine, the major metabolite, can further undergo glucuronidation. Norbuprenorphine has been found to bind opioid receptors in-vitro; however, it has not been studied clinically for opioid-like activity. Naloxone undergoes direct glucuronidation to naloxone-3-glucuronide as well as N-dealkylation, and reduction of the 6-oxo group.
- A mass balance study of buprenorphine showed complete recovery of radiolabel in urine (30%) and feces (69%) collected up to 11 days after dosing. Almost all of the dose was accounted for in terms of buprenorphine, norbuprenorphine, and two unidentified buprenorphine metabolites. In urine, most of buprenorphine and norbuprenorphine was conjugated (buprenorphine, 1% free and 9.4% conjugated; norbuprenorphine, 2.7% free and 11% conjugated). In feces, almost all of the buprenorphine and norbuprenorphine were free (buprenorphine, 33% free and 5% conjugated; norbuprenorphine, 21% free and 2% conjugated). Buprenorphine has a mean elimination half-life from plasma ranging from 24 to 42 hours and naloxone has a mean elimination half-life from plasma ranging from 2 to 12 hours.
- CYP3A4 Inhibitors and Inducers: Subjects receiving buprenorphine sublingual tablet should be monitored if inhibitors of CYP3A4 such as azole antifungal agents (e.g., ketoconazole), macrolide antibiotics (e.g., erythromycin) or HIV protease inhibitors and may require dose-reduction of one or both agents. The interaction of buprenorphine with all CYP3A4 inducers has not been studied, therefore it is recommended that patients receiving buprenorphine sublingual tablet be monitored for signs and symptoms of opioid withdrawal if inducers of CYP3A4 (e.g., phenobarbital, carbamazepine, phenytoin, rifampicin) are co-administered.
- Buprenorphine has been found to be a CYP2D6 and CYP3A4 inhibitor and its major metabolite, norbuprenorphine, has been found to be a moderate CYP2D6 inhibitor in in-vitro studies employing human liver microsomes. However, the relatively low plasma concentrations of buprenorphine and norbuprenorphine resulting from therapeutic doses are not expected to raise significant drug-drug interaction concerns.

## Nonclinical Toxicology
- Buprenorphine has been shown to have differences in bioavailability compared to other buprenorphine/naloxone-containing sublingual products. The exposure margins listed below are based on body surface area comparisons (mg/m2) to the recommended human sublingual dose of 16 mg buprenorphine via Suboxone, which is equivalent to a human sublingual dose of 11.4 mg buprenorphine via ZUBSOLV.
- A carcinogenicity study of buprenorphine/naloxone (4:1 ratio of the free bases) was performed in Alderley Park rats. Buprenorphine/naloxone was administered in the diet at doses of approximately 7, 31, and 123 mg/kg/day for 104 weeks (estimated exposure was approximately 4, 18, and 44 times the recommended human sublingual dose based on buprenorphine AUC comparisons). A statistically significant increase in Leydig cell adenomas was observed in all dose groups. No other drug-related tumors were noted.
- Carcinogenicity studies of buprenorphine were conducted in Sprague-Dawley rats and CD-1 mice. Buprenorphine was administered in the diet to rats at doses of 0.6, 5.5, and 56 mg/kg/day (estimated exposure was approximately 0.4, 3, and 35 times the recommended human sublingual dose) for 27 months. As in the buprenorphine/naloxone carcinogenicity study in rat, statistically significant dose-related increases in Leydig cell tumors occurred. In an 86-week study in CD-1 mice, buprenorphine was not carcinogenic at dietary doses up to 100 mg/kg/day (estimated exposure was approximately 30 times the recommended human sublingual dose).
- The 4:1 combination of buprenorphine and naloxone was not mutagenic in a bacterial mutation assay (Ames test) using four strains of S. typhimurium and two strains of E. coli. The combination was not clastogenic in an in vitro cytogenetic assay in human lymphocytes or in an IV micronucleus test in the rat.
- Buprenorphine was studied in a series of tests utilizing gene, chromosome, and DNA interactions in both prokaryotic and eukaryotic systems. Results were negative in yeast (S. cerevisiae) for recombinant, gene convertant, or forward mutations; negative in Bacillus subtilis "rec" assay, negative for clastogenicity in CHO cells, Chinese hamster bone marrow and spermatogonia cells, and negative in the mouse lymphoma L5178Y assay.
- Results were equivocal in the Ames test: negative in studies in two laboratories, but positive for frame shift mutation at a high dose (5mg/plate) in a third study. Results were positive in the Green-Tweets (E. coli) survival test, positive in a DNA synthesis inhibition (DSI) test with testicular tissue from mice, for both in vivo and in vitro incorporation of thymidine, and positive in unscheduled DNA synthesis (UDS) test using testicular cells from mice.
- Dietary administration of buprenorphine in the rat at dose levels of 500 ppm or greater (equivalent to approximately 47 mg/kg/day or greater; estimated exposure approximately 28 times the recommended human sublingual dose) produced a reduction in fertility demonstrated by reduced female conception rates. A dietary dose of 100 ppm (equivalent to approximately 10 mg/kg/day; estimated exposure approximately 6 times the recommended human sublingual dose) had no adverse effect on fertility.

# Clinical Studies
There is limited information regarding Buprenorphine (mucous membrane) Clinical Studies in the drug label.

# How Supplied
- Buprenorphine sublingual tablets are,menthol-flavored white tablets supplied in aluminum/aluminum child resistant unit dose blister packages. Buprenorphine is available in two dosage strengths:
- Buprenorphine/naloxone 1.4 mg/0.36 mg, triangular shape, and
- Buprenorphine/naloxone 5.7 mg/1.4 mg, round shape
- NDC 54123-914-30 (buprenorphine/naloxone 1.4 mg /0.36 mg) sublingual tablet  310 tablets per carton
- NDC 54123-957-30 (buprenorphine/naloxone 5.7 mg/1.4 mg) sublingual tablet 310 tablets per carton

## Storage
- Store at 20-25C (68-77F), excursions permitted to 15-30C (59-86F)
- Patients should be advised to store buprenorphine-containing medications safely and out of sight and reach of children. Destroy any unused medication appropriately

# Images

## Drug Images

## Package and Label Display Panel

# Patient Counseling Information
- Before initiating treatment with buprenorphine sublingual tablets, explain the points listed below to caregivers and patients. Instruct patients to read the Medication Guide each time buprenorphine is dispensed because new information may be available.
- Patients should be warned that it is extremely dangerous to self-administer non-prescribed benzodiazepines or other CNS depressants (including alcohol) while taking buprenorphine sublingual tablets. Patients prescribed benzodiazepines or other CNS depressants should be cautioned to use them only as directed by their physician.
- Patients should be advised that buprenorphine sublingual tablets contain an opioid that can be a target for people who abuse prescription medications or street drugs. Patients should be cautioned to keep their tablets in a safe place, and to protect them from theft.
- Patients should be instructed to keep buprenorphine sublingual tablets in a secure place, out of the sight and reach of children. Accidental or deliberate ingestion by a child may cause respiratory depression that can result in death. Patients should be advised that if a child is exposed to buprenorphine sublingual tablets, medical attention should be sought immediately.
- Patients should be advised never to give buprenorphine sublingual tablets to anyone else, even if he or she has the same signs and symptoms. It may cause harm or death.
- Patients should be advised that selling or giving away this medication is against the law.
- Patients should be cautioned that buprenorphine sublingual tablets may impair the mental or physical abilities required for the performance of potentially dangerous tasks such as driving or operating machinery. Caution should be taken especially during drug induction and dose adjustment and until individuals are reasonably certain that buprenorphine therapy does not adversely affect their ability to engage in such activities.
- Patients should be advised not to change the dosage of buprenorphine sublingual tablets without consulting their physician.
- Patients should be advised to take buprenorphine sublingual tablets once a day.
- Patients should be advised that if they miss a dose of buprenorphine they should take it as soon as they remember. If it is almost time for the next dose, they should skip the missed dose and take the next dose at the regular time.
- Patients should be informed that buprenorphine sublingual tablets can cause drug dependence and that withdrawal signs and symptoms may occur when the medication is discontinued.
- Patients seeking to discontinue treatment with buprenorphine for opioid dependence should be advised to work closely with their physician on a tapering schedule and should be apprised of the potential to relapse to illicit drug use associated with discontinuation of opioid agonist/partial agonist medication-assisted treatment.
- Patients should be cautioned that, like other opioids, buprenorphine sublingual tablets may produce orthostatic hypotension in ambulatory individuals.
- Patients should inform their physician if any other prescription medications, over-the-counter medications, or herbal preparations are prescribed or currently being used.
- Advise females of reproductive potential, who become pregnant or are planning to become pregnant, to consult their physician regarding the possible effects of using buprenorphine sublingual tablets during pregnancy.
- Advise women who are breastfeeding to monitor the infant for drowsiness and difficulty breathing.
- Patients should inform their family members that, in the event of emergency, the treating physician or emergency room staff should be informed that the patient is physically dependent on an opioid and that the patient is being treated with buprenorphine sublingual tablets.
- Refer to the Medication Guide for additional information regarding the counseling information.
- Disposal of Unused buprenorphine Sublingual Tablets
- Unused buprenorphine sublingual tablets should be disposed of as soon as they are no longer needed. Unused tablets should be flushed down the toilet.
- Manufactured for Orexo US, Inc. by Orexo AB with AAIPharma Wilmington, North Carolina
- Keep buprenorphine in a secure place away from children. If a child accidentally takes buprenorphine, this is a medical emergency and can result in death. Get emergency help right away.
- Read this Medication Guide before you start taking buprenorphine and each time you get a refill. There may be new information. This Medication Guide does not take the place of talking to your doctor. Talk to your doctor or pharmacist if you have questions about buprenorphine.
- nShare the important information in this Medication Guide with members of your household.
- Buprenorphine can cause serious and life-threatening breathing problems. Call your doctor right away or get emergency help if:
- You feel faint, dizzy, or confused
- Your breathing gets much slower than is normal for you
- These can be signs of an overdose or other serious problems.
- Do not switch from buprenorphine to other medicines that contain buprenorphine without talking with your doctor. The amount of buprenorphine in a dose of buprenorphine is not the same as the amount of buprenorphine in other medicines that contain buprenorphine. Your doctor will prescribe a starting dose of buprenorphine that may be different than other buprenorphine containing medicines you may have been taking.
- Buprenorphine contains an opioid that can cause physical dependence.
- Do not stop taking buprenorphine without talking to your doctor. You could become sick with uncomfortable withdrawal signs and symptoms because your body has become used to this medicine.
- Physical dependence is not the same as drug addiction.
- Buprenorphine is not for occasional or "as needed" use.
- An overdose, and even death, can happen if you take benzodiazepines, sedatives, tranquilizers, or alcohol while using buprenorphine. Ask your doctor what you should do if you are taking one of these.
- Call a doctor or get emergency help right away if you:
- Feel sleepy and uncoordinated
- Have blurred vision
- Have slurred speech
- Cannot think well or clearly
- Have slowed reflexes and breathing
- Do not inject ("shoot-up") buprenorphine. Injecting buprenorphine may cause life-threatening infections and other serious health problems.
- Injecting buprenorphine may cause serious withdrawal symptoms such as pain, cramps, vomiting, diarrhea, anxiety, sleep problems, and cravings.
- In an emergency, have family members tell the emergency department staff that you are physically dependent on an opioid and are being treated with buprenorphine.
- Buprenorphine is a prescription medicine used to treat adults who are addicted to opioid drugs (either prescription or illegal); as part of a complete treatment program that also includes counseling and behavioral therapy.
- Buprenorphine is a controlled substance (CIII) because it contains buprenorphine, which can be a target for people who abuse prescription medicines or street drugs. Keep your buprenorphine in a safe place to protect it from theft. Never give your buprenorphine to anyone else; it can cause death or harm them. Selling or giving away this medicine is against the law.
- It is not known if buprenorphine is safe or effective in children.
- Do not take buprenorphine if you are allergic to buprenorphine or naloxone.
- Buprenorphine may not be right for you. Before taking buprenorphine, tell your doctor if you:
- Have trouble breathing or lung problems
- Have an enlarged prostate gland (men)
- Have a head injury or brain problem
- Have problems urinating
- Have a curve in your spine that affects your breathing
- Have liver or kidney problems
- Have gallbladder problems
- Have adrenal gland problems
- Have Addison's disease
- Have low thyroid (hypothyroidism)
- Have a history of alcoholism
- Have mental problems such as hallucinations (seeing or hearing things that are not there)
- Have any other medical condition
- Are pregnant or plan to become pregnant. It is not known if buprenorphine will harm your unborn baby. If you take buprenorphine while pregnant, your baby may have symptoms of withdrawal at birth. Talk to your doctor if you are pregnant or plan to become pregnant.
- Are breastfeeding or plan to breastfeed. buprenorphine can pass into your breast milk and may harm your baby. Talk to your doctor about the best way to feed your baby if you take buprenorphine. Monitor your baby for increased sleepiness and breathing problems.
- Tell your doctor about all the medicines you take, including prescription and over-the-counter medicines, vitamins, and herbal supplements.
- Buprenorphine may affect the way other medicines work and other medicines may affect how buprenorphine works. Some medicines may cause serious or life-threatening medical problems when taken with buprenorphine.
- Sometimes the doses of certain medicines and buprenorphine may need to be changed if used together. Do not take any medicine while using buprenorphine until you have talked with your doctor. Your doctor will tell you if it is safe to take other medicines while you are using buprenorphine.
- Be especially careful about taking other medicines that may make you sleepy, such as pain medicines, tranquilizers, sleeping pills, anxiety medicines, or antihistamines.
- Know the medicines you take. Keep a list of them to show your doctor or pharmacist each time you get a new medicine.
- Always take buprenorphine exactly as your doctor tells you. Your doctor may change your dose after seeing how it affects you. Do not change your dose unless your doctor tells you to change it.
- Do not take buprenorphine more often than prescribed by your doctor.
- You may be prescribed a dose of 2 or more buprenorphine sublingual tablets at the same time.
- Take buprenorphine 1 time a day.
- Do not cut, crush, break, chew or swallow the tablet. Your doctor should show you how to take buprenorphine the right way.
- Follow the same instructions every time you take a dose of buprenorphine.
- Buprenorphine comes in a blister pack with 10 blister units. Each blister unit contains a buprenorphine tablet.
- Take the dose prescribed by your doctor as follows:
- While buprenorphine is dissolving, do not chew or swallow the tablet because the medicine will not work as well.
- Do not eat or drink anything until the buprenorphine tablet has completely dissolved.
- Talking while the tablet is dissolving can affect how well the medicine in buprenorphine is absorbed.
- If you miss a dose of buprenorphine, take your medicine when you remember. If it is almost time for your next dose, skip the missed dose and take the next dose at your regular time. Do not take 2 doses at the same time unless your doctor tells you to. If you are not sure about your dosing, call your doctor.
- Do not stop taking buprenorphine suddenly. You could become sick and have withdrawal symptoms because your body has become used to the medicine. Physical dependence is not the same as drug addiction. Your doctor can tell you more about the differences between physical dependence and drug addiction. To have fewer withdrawal symptoms, ask your doctor how to stop using buprenorphine the right way.
- If you take too much buprenorphine go to the nearest hospital emergency room right away.
- Do not drive, operate heavy machinery, or perform any other dangerous activities until you know how this medication affects you. Buprenorphine can cause drowsiness and slow reaction times. This may happen more often in the first few weeks of treatment when your dose is being changed, but can also happen if you drink alcohol or take other sedative drugs when you take buprenorphine.
- You should not drink alcohol while taking buprenorphine, as this can lead to loss of consciousness or even death.
- Buprenorphine can cause serious side effects, including:
- See "What is the most important information I should know about buprenorphine?"
- Respiratory problems. You have a higher risk of death and coma if you take buprenorphine with other medicines, such as benzodiazepines.
- Sleepiness, dizziness, and problems with coordination
- Dependency or abuse
- Liver problems. Call your doctor right away if you notice any of these signs of liver problems: Your skin or the white part of your eyes turning yellow (jaundice), urine turning dark, stools turning light in color, you have less of an appetite, or you have stomach (abdominal) pain or nausea. Your doctor should do tests before you start taking and while you take buprenorphine.
- Allergic reaction. You may have a rash, hives, swelling of your face, wheezing, or loss of blood pressure and consciousness. Call a doctor or get emergency help right away.
- Opioid withdrawal. This can include: shaking, sweating more than normal, feeling hot or cold more than normal, runny nose, watery eyes, goose bumps, diarrhea, vomiting and muscle aches. Tell your doctor if you develop any of these symptoms
- Decrease in blood pressure. You may feel dizzy if you get up too fast from sitting or lying down.
- Headache
- Nausea
- Vomiting
- Increased sweating
- Constipation
- Drug withdrawal syndrome
- Decrease in sleep (insomnia)
- Pain
- Swelling of the extremities
- Tell your doctor about any side effect that bothers you or that does not go away.
- These are not all the possible side effects of buprenorphine. For more information, ask your doctor or pharmacist.
- Call your doctor for medical advice about side effects. You may report side effects to the FDA at 1-800-FDA-1088.
- Store buprenorphine at room temperature between 68F to 77F (20C to 25C).
- Keep buprenorphine in a safe place, out of the sight and reach of children.
- Dispose of unused buprenorphine sublingual tablets as soon as you no longer need them.
- Flush unused tablets down the toilet.
- Medicines are sometimes prescribed for purposes other than those listed in a Medication Guide. Do not use buprenorphine for a condition for which it was not prescribed. Do not give buprenorphine to other people, even if they have the same symptoms you have. It may harm them and it is against the law.
- This Medication Guide summarizes the most important information about buprenorphine. If you would like more information, talk to your doctor or pharmacist. You can ask your doctor or pharmacist for information that is written for health professionals.
- For more information, call 1-888-buprenorphine (1-888-982-7658).
- Active Ingredients: buprenorphine and naloxone
- Inactive Ingredients: mannitol, citric acid, sodium citrate, microcrystalline cellulose, croscarmellose sodium, sucralose, silicon dioxide, sodium stearyl fumarate, and menthol flavor.
- This Medication Guide has been approved by the U.S. Food and Drug Administration.

# Precautions with Alcohol
Alcohol-Buprenorphine interaction has not been established. Talk to your doctor about the effects of taking alcohol with this medication.

# Brand Names
There is limited information regarding Buprenorphine (mucous membrane) Brand Names in the drug label.

# Look-Alike Drug Names
There is limited information regarding Buprenorphine (mucous membrane) Look-Alike Drug Names in the drug label.

# Drug Shortage Status

# Price