Transferring Patients From Methadone to Buprenorphine: The Feasibility and Evaluation of Practice Guidelines

Abstract

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Managing opioid withdrawal precipitated by buprenorphine with buprenorphine

“…At 1020 h (2 h after first dose), his COWS had more than doubled to 33 with signs and symptoms including tachycardia, vomiting and diarrhoea, piloerection, dilated pupils, marked tremor, nasal stuffiness, bone and joint aches, extreme irritability and agitation. A precipitated opioid withdrawal was diagnosed-based on accepted definition of an increase in COWS of 6 or more within 2 h of initiating buprenorphine treatment [4]. Discussions regarding management options were held between the treating team, his prescriber and the patient.…”

“…In an opioid-dependent person, buprenorphine can displace opioid agonists of lower receptor affinity (e.g. heroin, methadone) from the receptors, without full activation (partial agonism), leading to a 'precipitated' opioid withdrawal [3,4]. Precipitated opioid withdrawal is characterised by the rapid onset of opioid withdrawal symptoms (such as aches, nausea and vomiting, diarrhoea and abdominal cramps, dilated pupils, running nose, yawning) within 1-2 h following the first dose of buprenorphine, and gradually subsiding over the subsequent 6-24 h. This is a well-recognised adverse outcome from buprenorphine induction [3][4][5], and was found to occur in 9% of buprenorphine inductions [6].…”

“…heroin, methadone) from the receptors, without full activation (partial agonism), leading to a 'precipitated' opioid withdrawal [3,4]. Precipitated opioid withdrawal is characterised by the rapid onset of opioid withdrawal symptoms (such as aches, nausea and vomiting, diarrhoea and abdominal cramps, dilated pupils, running nose, yawning) within 1-2 h following the first dose of buprenorphine, and gradually subsiding over the subsequent 6-24 h. This is a well-recognised adverse outcome from buprenorphine induction [3][4][5], and was found to occur in 9% of buprenorphine inductions [6]. Risk factors for precipitated withdrawal include transferring from long-acting agents such as methadone, recent benzodiazepine use, no past patient experience with buprenorphine, and a low initial dose of buprenorphine/naloxone [6].…”

“…The Clinical Opiate Withdrawal Scale (COWS) is a tool that can be used to guide the diagnosis of an (02) 9332 8777; Fax: (02) 9332 8700; E-mail: hester.wilson@health.nsw.gov.au established opioid withdrawal [7]. Once the patient is in opioid withdrawal, buprenorphine can be started with a decreased risk of precipitating a withdrawal [4]. Despite the use of clinical monitoring tools like the COWS, precipitated withdrawal can still occur, as demonstrated in our case.…”

Transition from methadone to subcutaneous buprenorphine depot in patients with opioid use disorder in custodial setting – a case series

“…No accepted algorithm for switching methadone to buprenorphine exits (5). Typically, a reduction of methadone to about 30-40 mg and transition to buprenorphine sublingual after 24-48 hours is recommended (5,23,24). The time interval between the methadone and buprenorphine exposure and the level of physical dependence are of relevance for the development of withdrawal symptoms.…”