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If the patient arrives on site in an emergency situation with an active prescription for any buprenorphine, the approach is a bit more challenging compared to elective surgery.

But before traveling down this road, let’s first ask; what compelling justification is there for combining buprenorphine with naloxone in the first place? Consider that buprenorphine is 90-95% bound to mu-1 receptors and has a superior binding affinity compared to naloxone.

How then did Reckitt Benckiser ever convince the FDA that this is a necessary or safer combination compared to buprenorphine alone? Jones shares a diagram that is ironically referenced to the eminent Suboxone manufacturer, Reckitt Benckiser.Here’s the figure from Jones’ writing with italicized dialogue from his article.Heroin, Buprenorphine, and Naloxone Effects at the Mu Opioid Receptor Heroin, buprenorphine, and naloxone (represented above by blue polygons) produce contrasting effects because they interact differently with the brain’s mu opioid receptors (red pentagons).Certain literature (available upon request) misinterprets previously published recommendations and makes the leap that methadone 30-40mg/day could be used in the acute surgery setting to replace buprenorphine. The methadone could stay around for quite some time (half-life of 10-60 hours)…just enough time to cause significant toxicity as the buprenorphine wears off.Others say use hydromorphone by continuous IV infusion.

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