Unusual Route of Buprenorphine Administration: An Alternative Approach for Bypassing Adverse Drug Reactions

•Buprenorphine therapeutic effects may be emerged at very small doses•Doses as 30 folds lower than approved therapeutic dosage show pharmacologic effects•Almost all of documented buprenorphine adverse effects may occur at too small doses•Swallowing buprenorphine sublingual tablet bypasses common adverse reactions•Swallowing buprenorphine as a new approach could be used to treat opioid dependence Tramadol abuse is a critical and growing health concern in Asia. In Iran, tramadol abuse arises most commonly as a result of self-medicating that leads to tramadol dependence. Buprenorphine, a partial agonist of mu opioid receptors approved for the treatment of tramadol dependence, is administered sublingually due to its extensive first-pass metabolism and resulting low oral bioavailability. A 50-year-old man presenting with tramadol dependence after self-medicating for chronic low back pain experienced adverse reactions to a minimal dosage (0.8 mg) of sublingual buprenorphine. He was treated successfully with a modified protocol composed of swallowing sublingual tablets (0.2 mg/day initially, which increased to 0.2 mg every 12 hours during maintenance therapy). This unusual case suggests that swallowing buprenorphine sublingual tablets may prevent adverse effects and reduce the rate of treatment dropout.