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Could I get advice for transitioning a problematic legacy methadone pain patient to buprenorphine? 
 

he’s on 20mg TID methadone and the traditional approach will take months. 
I’ve never done bupe microdosing. Any advice or protocols? I was reading there are 3 week ones. Thanks! 

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Matt, I do not think any of the protocols are supported by evidence so you should use it as a guideline and go with your judgement following patient's response.

Some initial questions? Why is the pt on tid methadone? is it used for pain? How much time you have for transition? It can be accomplished inpatient over 3-4 days or 2-4 weeks outpatient.  

I would first transition to once daily dose and give it 1 week to settle. If stable, and the patient is otherwise fine to tolerate transition (eg., no opioids, no heavy Benzos/alcohol use, no active psychiatric sxs etc) you can either drop methadone to 50 and 40 at weekly intervals or just go directly to 40 mg. I would start using adjunctive medications targeting withdrawal symptoms  early in the process to prevent/minimize withdrawal.

Do you think that continuing methadone while you titrate BUP is clinically important? It would take at least week, and most anecdotal evidence is with short-acting agonists, not clear how this would apply to methadone.

I would stop methadone, increase adjunctive meds to treat emerging symptoms, and start titrating BUP with small initial doses around 24 hours after stopping methadone, e.g. start with 0.25 mg and double every 3 hr or so until you get to 16 mg, so 48 hrs later, you will have switched the patient to BUP with little with likely little withdrawal.

         

      

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thanks, that's very helpful. It's a depressed chronic headache patient very attached to taking methadone 20mg TID, but a number of problematic behaviors (and probably opioids are causing some of his issues) so we want to switch to bup/nal. His insurance won't cover inpatient detox regrettably. I suspect psychiatric symptoms are going to be an issue but was planning to keep going with things until he's on bupe.  My previous advice was waiting til 20-30mg methadone before switching so it's good to know I can do higher.

 

 

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Hope you don't mind me asking,  but If you do switch to Buprenorphine (I am assuming you are referring to the combined product with Naloxone), there is no guarantee the problematic behaviors will resolve. Also, methadone is a more potent analgesic than Buprenorphine so the patient may repeatedly ask for his Bupe dose to be increased and this will further obscure the treatment goals (pain control vs OUD). And since you feel opioids in general have been an issue for this patients, why continue with them?

Thanks.

 

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Great points! It's a patient of a colleagues. We're hoping sedation, depression and polypharmacy risk will all decrease once he's off methadone. We're planning to hold at 8/2mg suboxone TID and not escalate. I've found my colleagues feel more comfortable holding the line with bupe doses with our OUD work for some reason than with chronic pain opioid patients. But the yelling at staff and intermittent cocaine use probably won't completely go away. Just better to do that and be on suboxone. I agree it'd be better if him (and many patients like him) weren't on opioids at all

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