Transitioning Hospitalized Patients with Opioid Use Disorder from Methadone to Buprenorphine without a Period of Opioid Abstinence Using a Microdosing Protocol

Abstract

Study Objective Buprenorphine, a partial μ‐opioid agonist, is an effective treatment for opioid use disorder that conventionally requires symptoms of withdrawal before initiation to avoid precipitating withdrawal. Our institution implemented a microdosing approach to transition patients from full μ‐opioid agonists to buprenorphine without requiring patients to undergo a period of opioid abstinence. Little has been published about this strategy in the inpatient setting in the United States, and even less has been published dealing with the transition from methadone to buprenorphine. Our objective was to demonstrate that a microdosing protocol to transition patients from methadone to buprenorphine can be feasibly implemented in a U.S. hospital setting. Design Case series. Patients Three hospitalized adults with opioid use disorder who received a 1‐week buprenorphine microdosing protocol. Measurements and Main Results In January 2019, we implemented a 1‐week buprenorphine microdosing protocol for hospitalized adult patients with opioid use disorder who were initially stabilized on methadone and wished to start buprenorphine. We gave low‐dose buprenorphine concurrently with each patient's full dose of methadone, and the buprenorphine dose was gradually titrated up over 7 days. On day 8, methadone was abruptly discontinued. The buprenorphine dose was further increased based on clinical judgment. All three patients were successfully transitioned from methadone 40–100 mg/day to buprenorphine 12–16 mg/day with minimal symptoms of opioid withdrawal. One patient relapsed and was lost to follow‐up; two remained in treatment. Conclusion A protocol using microdosing of buprenorphine can successfully transition patients receiving full μ‐opioid agonist therapy, including methadone, to buprenorphine without the need for a period of opioid abstinence.

New directions in the treatment of opioid withdrawal

“…With this method, in a case series of three patients in an inpatient setting on 40 mg (n=2) and 100 mg (n=1), patients were successfully withdrawn from methadone and stabilised on 12-16 mg buprenorphine daily with manageable withdrawal symptoms. 51 Rigorous clinical trials are required to validate this method before being implemented on a broader scale.…”

“…7,50 Buprenorphine microdosing might help alleviate withdrawal symptoms when transitioning from high doses, although more research is needed regarding the standardisation of doses and establishment of a protocol. 51 As buprenorphine becomes more widely available and methadone falls increasingly out of favour, this clinical scenario could become more common and is a useful direction for future research.…”

“…• Buprenorphine microdosing has promise but requires evaluation in randomised controlled trials 51 Improving induction rates onto extended-release naltrexone 8,9,56…”

Ambulatory microdose induction of buprenorphine‐naloxone in two adolescent patients with sickle cell disease

“…3 Case reports describe alternative approaches utilizing small, frequent doses of buprenorphine-naloxone to avoid withdrawal symptoms, and rapidly transition patients off full agonist opioids. [4][5][6][7][8][9][10][11][12][13] None of these case studies include adolescents or individuals with SCD.…”

Ambulatory Micro-Dose Induction of Buprenorphine-Naloxone in Two Adolescent Patients With Sickle Cell Disease

“…2 Case reports describe alternative approaches utilizing small, frequent doses of buprenorphinenaloxone to avoid withdrawal symptoms and rapidly transition patients off full agonist opioids. [3][4][5][6][7][8][9][10][11][12] None of these case studies include adolescents or individuals with SCD.…”