Microdose induction of buprenorphine-naloxone in a patient using high dose methadone: A case report

Abstract

Background Buprenorphine is a partial mu-opioid receptor agonist approved for the treatment of opioid dependence. The risk of withdrawal symptoms and wait time required to safely initiate buprenorphine provides challenges to both patients and providers. Microdose induction is proposed as a possible solution to ease the transition to buprenorphine; however, little data has been published to date on patients stabilized on methadone doses greater than 100 mg. Case Report A 29-year-old patient stabilized on methadone 105 mg was successfully transitioned to sublingual buprenorphine-naloxone using a 7-day microdose protocol on an inpatient psychiatric service. During the transition, the patient reported only minimal symptoms. Conclusion This report adds to the growing literature supporting the use of a microdose induction to initiate buprenorphine-naloxone. Additionally, this approach may be significant for patients stabilized on high doses of methadone who may not be able to tolerate a traditional buprenorphine induction.

Transitioning From High-dose Methadone to Buprenorphine Using a Microdosing Approach: Unique Considerations at ASAM Level 3 Facilities

“…Therefore, a pragmatic strategy for level 3 settings relies on splitting transmucosal buprenorphine formulations approved for OUD into microdoses. The ability to effectively divide transmucosal buprenorphine formulations into evenly distributed doses has been cited as a concern 5,10,16,17 . However, numerous reports suggest that splitting buprenorphine 2 mg tablets (or buprenorphine/naloxone 2/0.5 mg films or tablets) into quarters is a reasonable strategy to achieve sublingual buprenorphine doses of 0.5 mg required for microdosing transitions 5,16,17 .…”

“…The ability to effectively divide transmucosal buprenorphine formulations into evenly distributed doses has been cited as a concern. 5,10,16,17 However, numerous reports suggest that splitting buprenorphine 2 mg tablets (or buprenorphine/naloxone 2/0.5 mg films or tablets) into quarters is a reasonable strategy to achieve sublingual buprenorphine doses of 0.5 mg required for microdosing transitions. 5,16,17 We infer that any variability in 0.5 mg and 1 mg doses due to tablet splitting did not have a clinically significant impact on this patient's induction experience.…”

“…5,10,16,17 However, numerous reports suggest that splitting buprenorphine 2 mg tablets (or buprenorphine/naloxone 2/0.5 mg films or tablets) into quarters is a reasonable strategy to achieve sublingual buprenorphine doses of 0.5 mg required for microdosing transitions. 5,16,17 We infer that any variability in 0.5 mg and 1 mg doses due to tablet splitting did not have a clinically significant impact on this patient's induction experience. However, the clinical significance of using inexact dose quantities in the early stage of microdosing warrants additional study.…”

“…[4][5][6][7][8][9][10][11][12][13][14][15][16][17][18] Case reports have demonstrated the feasibility and tolerability of a microdosing strategy when transitioning hospitalized patients directly from methadone (up to 105 mg daily) to buprenorphine without a period of methadone tapering or abstinence. 5,6 However, reports about patients' conditions after the acute transition period have been minimal. American Society of Addiction Medicine (ASAM) level 3 facilities provide unique settings for monitoring and dose adjustment during microdosing transitions and in the weeks that follow.…”

Microdose Induction of Buprenorphine in a Patient Using Tianeptine

“…It is believed that the gradual increase in buprenorphine levels can prevent an abrupt shift from full to partial agonism that may otherwise been seen with higher dose inductions 14 . Thus far, microdose induction has proven useful with patients dependent on multiple opioid agonists, including heroin and methadone 14,15 …”