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# TUSQ OD ## Overview TUSQ OD is a sublingual formulation of **buprenorphine and naloxone**. Buprenorphine is a partial opioid agonist, and naloxone is an opioid antagonist. The sublingual route bypasses first-pass metabolism, leading to rapid absorption. ## Primary Indications * **Opioid Use Disorder (OUD):** Management of opioid dependence. * **Chronic Pain:** For pain severe enough to require daily, long-term opioid treatment, and for which alternative treatment options are inadequate. ## Adult Dosing **OUD:** Dosing is highly individualized and titrated based on patient response and opioid tolerance. * **Induction:** Initiated when the patient is in mild to moderate withdrawal. * Day 1: Up to 16 mg/day. * Day 2 onwards: Typically 8-16 mg once daily. * **Maintenance:** Once stabilized, a typical maintenance dose is 16 mg once daily. Maximum dose is generally considered 24 mg/day, but some protocols may allow higher doses for severe OUD. **Chronic Pain:** Dosing is individualized and should be titrated to the lowest effective dose. * **Initial dose:** Typically 5-10 mg once daily. * **Titration:** Increase dose every 3-7 days as needed. * **Maximum dose:** Generally 40 mg once daily. *Note: Specific induction and titration protocols can vary significantly. Consult local treatment guidelines.* ## Pediatric Dosing TUSQ OD is **not approved for use in pediatric patients**. Safety and efficacy have not been established. ## Dose Adjustments * **Hepatic Impairment:** Use with caution. Buprenorphine is metabolized by the liver. Dose reduction may be necessary. * **Renal Impairment:** No specific dose adjustment is typically required, but caution is advised. ## Contraindications * Hypersensitivity to buprenorphine or naloxone. * Severe respiratory impairment. * Severe hepatic impairment. * Acute alcohol intoxication. * Opioid-naïve patients for OUD treatment (unless very carefully monitored). ## Adverse Effects * **Common:** Headache, nausea, vomiting, constipation, dizziness, drowsiness, sweating, insomnia, oral hypoesthesia, tongue discomfort. * **Serious:** Respiratory depression (especially with co-administration of other CNS depressants), opioid withdrawal symptoms (if precipitated), liver injury, neonatal withdrawal syndrome (if used during pregnancy), serotonin syndrome (with serotonergic agents). ## Key Drug Interactions * **CNS Depressants (benzodiazepines, alcohol, sedatives, hypnotics, antipsychotics, other opioids):** Increased risk of severe sedation, respiratory depression, coma, and death. * **Serotonergic Drugs (SSRIs, SNRIs, MAOIs, tricyclic antidepressants, triptans, fentanyl, tramadol, lithium, St. John's Wort):** Risk of serotonin syndrome. * **CYP3A4 Inhibitors (e.g., ketoconazole, ritonavir):** May increase buprenorphine plasma concentrations. * **CYP3A4 Inducers (e.g., rifampin, carbamazepine, phenytoin):** May decrease buprenorphine plasma concentrations. ## Monitoring * **OUD:** Monitor for signs of withdrawal, misuse, diversion, and overdose. Assess functional status and adherence to treatment. * **Chronic Pain:** Monitor pain relief, functional improvement, and signs of opioid toxicity. * **Liver Function Tests:** Periodically, especially in patients with pre-existing liver disease or risk factors. * **Respiratory Rate and Sedation Level:** Particularly during induction or when co-administered with other CNS depressants. ## Clinical Pearls * TUSQ OD is **not interchangeable** with other buprenorphine/naloxone products due to potential differences in bioavailability and formulation. * Educate patients on the risks of **precipitated withdrawal** if taken too soon after other opioids. * Advise patients to **avoid alcohol** and other CNS depressants. * Discuss the risks of **diversion and misuse**. * For OUD, treatment is often part of a **comprehensive care program** including counseling and behavioral therapies. * Sublingual absorption requires the film to be placed under the tongue and allowed to dissolve completely without chewing or swallowing. *** **Disclaimer:** This information is intended as a quick reference and does not replace the official prescribing information or professional medical advice. Always consult the most current drug monograph and clinical guidelines before prescribing or dispensing.