Transdermal Buprenorphine to Switch Patients from Higher Dose Methadone to Buprenorphine without Severe Withdrawal Symptoms

Hess, Melanie; Boesch, Lukas; Leisinger, R.; Stohler, Rudolf

doi:10.1111/j.1521-0391.2011.00159.x

Cited by 35 publications

(38 citation statements)

References 9 publications

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“…Once the target dose is reached, the full agonists can be stopped abruptly. Hess et al 26 have previously described a method of switching from doses between 70 and 100 mg methadone, but used transdermal patches and a quicker scheme of dose increases. In our clinical experience, this scheme can also lead to substantial withdrawal symptoms.…”

Section: Discussionmentioning

confidence: 99%

Use of microdoses for induction of buprenorphine treatment with overlapping full opioid agonist use: the “Bernese method”

Hämmig¹,

Kemter²,

Strasser³

et al. 2016

SAR

165

116

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BackgroundBuprenorphine is a partial µ-opioid receptor agonist used for maintenance treatment of opioid dependence. Because of the partial agonism and high receptor affinity, it may precipitate withdrawal symptoms during induction in persons on full µ-opioid receptor agonists. Therefore, current guidelines and drug labels recommend leaving a sufficient time period since the last full agonist use, waiting for clear and objective withdrawal symptoms, and reducing pre-existing full agonist therapies before administering buprenorphine. However, even with these precautions, for many patients the induction of buprenorphine is a difficult experience, due to withdrawal symptoms. Furthermore, tapering of the full agonist bears the risk of relapse to illicit opioid use.CasesWe present two cases of successful initiation of buprenorphine treatment with the Bernese method, ie, gradual induction overlapping with full agonist use. The first patient began buprenorphine with overlapping street heroin use after repeatedly experiencing relapse, withdrawal, and trauma reactivation symptoms during conventional induction. The second patient was maintained on high doses of diacetylmorphine (ie, pharmaceutical heroin) and methadone during induction. Both patients tolerated the induction procedure well and reported only mild withdrawal symptoms.DiscussionOverlapping induction of buprenorphine maintenance treatment with full µ-opioid receptor agonist use is feasible and may be associated with better tolerability and acceptability in some patients compared to the conventional method of induction.

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Section: Discussionmentioning

confidence: 99%

Use of microdoses for induction of buprenorphine treatment with overlapping full opioid agonist use: the “Bernese method”

Hämmig¹,

Kemter²,

Strasser³

et al. 2016

SAR

165

116

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“…Methadone is an alternative that may be used, however consider the added risk of adverse events. (30)(31)(32)44,(91)(92)(93) GRADE Quality: Moderate; Strength: Weak…”

Section: Recommendation 15mentioning

confidence: 99%

Canadian Guidelines on Opioid Use Disorder Among Older Adults

et al. 2020

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BackgroundIn Canada, rates of hospital admission from opioid overdose are higher for older adults (≥ 65) than younger adults, and opioid use disorder (OUD) is a growing concern. In response, Health Canada commissioned the Canadian Coalition of Seniors’ Mental Health to create guidelines for the prevention, screening, assessment, and treatment of OUD in older adults.MethodsA systematic review of English language literature from 2008–2018 regarding OUD in adults was conducted. Previously published guidelines were evaluated using AGREE II, and key guidelines updated using ADAPTE method, by drawing on current literature. Recommendations were created and assessed using the GRADE method.ResultsThirty-two recommendations were created. Prevention recommendations: it is key to prioritize non-pharmacological and non-opioid strategies to treat acute and chronic noncancer pain. Assessment recommendations: a comprehensive assessment is important to help discern contributions of other medical conditions. Treatment recommendations: buprenorphine is first line for both withdrawal management and maintenance therapy, while methadone, slow-release oral morphine, or naltrexone can be used as alternatives under certain circumstances; non-pharmacological treatments should be offered as an integrated part of care.ConclusionThese guidelines provide practical and timely clinical recommendations on the prevention, assessment, and treatment of OUD in older adults within the Canadian context.

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“…Previous protocols for transition from methadone to buprenorphine/naloxone have utilized a buprenorphine patch. Although the withdrawal experience may be less significant, it still remains present …”

Section: Discussionmentioning

confidence: 99%

Methadone to buprenorphine/naloxone induction without withdrawal utilizing transdermal fentanyl bridge in an inpatient setting—Azar method

2018

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Background and Objectives Although buprenorphine/naloxone is widely recognized as first‐line therapy for opioid use disorder, the requirement for moderate withdrawal prior to initiation in efforts to avoid precipitated withdrawal can be a barrier to its initiation. Methods We present a case utilizing transdermal fentanyl as a bridging treatment to eliminate withdrawal during the transition from methadone to buprenorphine/naloxone in a patient who had ongoing significant intravenous heroin use while on methadone. Results Patient was successfully transitioned from methadone to buprenorphine/naloxone without a period of withdrawal utilizing transdermal fentanyl as a bridge in an inpatient setting. Discussion and Conclusions Our experience indicates a transdermal depot of fentanyl allows for slow release and elimination while buprenorphine doses are introduced during an induction without presence of withdrawal, as quantified by serial clinical opiate withdrawal score. Scientific Significance This case report highlights ways to minimize barriers to induction of first‐line opioid substitution therapy, buprenorphine/naloxone, by eliminating withdrawal during induction phase utilizing a fentanyl bridge within the limitations of a transdermal fentanyl bridge in an inpatient setting. (Am J Addict 2018;XX:1–4)

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Transdermal Buprenorphine to Switch Patients from Higher Dose Methadone to Buprenorphine without Severe Withdrawal Symptoms

Cited by 35 publications

References 9 publications

Use of microdoses for induction of buprenorphine treatment with overlapping full opioid agonist use: the “Bernese method”

Use of microdoses for induction of buprenorphine treatment with overlapping full opioid agonist use: the “Bernese method”

Canadian Guidelines on Opioid Use Disorder Among Older Adults

Methadone to buprenorphine/naloxone induction without withdrawal utilizing transdermal fentanyl bridge in an inpatient setting—Azar method

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Transdermal Buprenorphine to Switch Patients from Higher Dose Methadone to Buprenorphine without Severe Withdrawal Symptoms

Cited by 35 publications

References 9 publications

Use of microdoses for induction of buprenorphine treatment with overlapping full opioid agonist use: the &ldquo;Bernese method&rdquo;

Use of microdoses for induction of buprenorphine treatment with overlapping full opioid agonist use: the &ldquo;Bernese method&rdquo;

Canadian Guidelines on Opioid Use Disorder Among Older Adults

Methadone to buprenorphine/naloxone induction without withdrawal utilizing transdermal fentanyl bridge in an inpatient setting—Azar method

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Product

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Use of microdoses for induction of buprenorphine treatment with overlapping full opioid agonist use: the “Bernese method”

Use of microdoses for induction of buprenorphine treatment with overlapping full opioid agonist use: the “Bernese method”