Accidental Transdermal Buprenorphine Patch Overdose in an Older Adult: A Case Report

Keywords

Buprenorphine, Transdermal patch, Medication errors, Opioid toxicity, Naloxone, Aged

Document Type

Case Report

Abstract

Background: Buprenorphine is an opioid that is generally used for chronic pain and opioid dependence. Its pharmacological ceiling effect on respiratory depression gives it a comparatively favorable safety profile relative to other opioids. Despite its safety profile, inappropriate use can still result in clinically significant opioid poisoning. This case report highlights a case of accidental buprenorphine overdose in an aged patient. It illustrates the clinical presentation and preventive considerations associated with this uncommon but critical event. Case presentation: A 65-year-old woman with recent left total knee replacement was brought to the Emergency Department (ED) after being found drowsy and unresponsive at home. Initial clinical presentations showed a somnolence patient with hypoxia. A comprehensive physical examination and investigations showed no clear evidence of a respiratory etiology nor intracranial pathology. Detailed history revealed the use of buprenorphine transdermal patches that were mistaken for wound dressings. Three transdermal patches of (Butrans\textregistered ), 10 mcg/hour were used simultaneously. Intervention/Outcome: The patient was treated for suspected opioid toxicity with naloxone 0.4 mg intravenously followed by an additional 0.8 mg intravenously resulting in a rapid improvement in consciousness and resolution of hypoxia. Eventually the patient was admitted for observation for 24 hours and was discharged the next day with no complications. Conclusion: This case highlights that buprenorphine transdermal patches can cause life-threatening opioid toxicity when misused. Elderly patients are particularly vulnerable due to medication errors and age-related physiological changes. Careful counseling, clear labeling and appropriate prescribing practices are essential to prevent similar adverse events.

Recommended Citation

Shogdar, Hashem; Aljohani, Ahmed; and Almubarak, Yousef (2026) "Accidental Transdermal Buprenorphine Patch Overdose in an Older Adult: A Case Report," Saudi Toxicology Journal: Vol. 3: Iss. 2, Article 2.
Available at: https://stj.researchcommons.org/journal/vol3/iss2/2

Subject Area

Forensic and Analytical Toxicology

Data Availability Statement

No datasets were generated or analyzed during the current study.

Ethical Approval

This case report was conducted according to the guidelines of the Declaration of Helsinki and approved by the Institutional Review Board of King Fahad Medical City, Riyadh Second Health Cluster, Saudi Arabia (Log No. 26-454; Approval Date: July 22, 2026).