Depending on the application form, buprenorphine is indicated for the palliation of moderate to severe acute or chronic pain with no neuralgic component (or when the neuralgia is otherwise treated, such as with pregabalin), or for peri-operative analgesia. For the treatment of chronic pain, the transdermal formulations (which were released in the United States in January 2011, but were available in Australia and many European countries years beforehand) are preferred. The intravenous formulation is mainly used in postoperative pain (for example, as patient controlled analgesia [PCA]).
Sublingual buprenorphine (also sometimes taken buccally) for pain is available in the United Kingdom, as well as the Republic of India, in dosages of 200 and 400µg. It is not available in the United States or in Canada, although Subutex or Suboxone (sublingual buprenorphine for addiction) is sometimes used off-label for this purpose, up to a dosage of 2 mg (the lowest-strength Subutex/Suboxone tablet). Sublingual formulations, such as Addnok, Temgesic, Subutex, and Suboxone, are us ed either as breakthrough medication for patients on transdermal treatment, or as monotherapy in cases where other treatments are not suitable.
The most severe and serious adverse reaction associated with opioid use in general is respiratory depression, the mechanism behind fatal overdose. Buprenorphine behaves differently than other opioids in this respect, as it shows a ceiling effect for respiratory depression. Moreover, former doubts on the antagonisation of the respiratory effects by naloxone have been disproved: Buprenorphine effects can be antagonised with a continuous infusion of naloxone. Concurrent use of buprenorphine and CNS depressants (such as alcohol or benzodiazepines) is not recommended as it may lead to fatal respiratory depression. Benzodiazepines, in prescribed doses, are not contraindicated in individuals tolerant to either opioids or benzodiazepines.
People on medium- to long-term maintenance with Suboxone or Subutex do not have a risk of overdose from buprenorphine alone, no matter what dosage is taken or route of administration it is taken by, due to the "ceiling effect" on respiratory depression. Overdoses occurring in maintenance patients are cases of multiple-drug intoxication, usually buprenorphine taken with excessive amounts of ethanol and/or benzodiazepine drugs. As a matter of course, all patients on buprenorphine maintenance are tolerant to opioids, and maintenance doses are always higher than the dose at which the "ceiling effect" on respiratory depression is reached (~3±1 milligrammes, depending on method of analysis).
People switching from other opiates should wait until mild to moderate withdrawal symptoms are encountered. Failure to do so can lead to the rapid onset of intense withdrawal symptoms, known as precipitated withdrawal. For short acting opioids such as codeine, hydrocodone, oxycodone, hydromorphone, pethidine, heroin, and morphine, 12"24 hours from the last dose is generally sufficient. For longer acting opioids such as methadone, 2"3 days from the last dose is needed to prevent precipitated withdrawal.