Outpatient Buprenorphine Patch Micro-Dosing as a Bridge for Patients on Methadone

Introduction:

Precipitated withdrawal is one of the largest barriers to routine utilization of buprenorphine. Lack of patient tolerance to the prolonged period of abstinence necessary for buprenorphine induction while on long acting opioids (I.E. methadone) places patients at significant risk of relapsing with illicit opioids.1-4 In the outpatient setting, abstinence is of particular concern as patients are exposed to stressors that exacerbate the risk for relapse. Outpatient use of the buprenorphine patch provides an ideal pharmacologic bridge from a long-acting opioid to buprenorphine, eliminating the need for a period of abstinence.

Case Series

Description:

We describe a series of three patients that required methadone for the treatment of acute pain while hospitalized. Prior to admission, their recovery plans included the use of buprenorphine for the treatment of opioid use disorder (OUD). Following hospitalizations, the patients were discharged with prescriptions for a methadone taper and short-acting opioids. The primary goal of the methadone taper was to ensure that the patients were on less than 30 mg of methadone daily prior to buprenorphine induction. The patients were prescribed the buprenorphine patch with instructions to begin the morning after the last dose of methadone. The patients were then prescribed supplemental buprenorphine/naloxone after 48 hours due to development of mild withdrawal symptoms inadequately treated by the buprenorphine patch. None of the patients developed adverse drug reactions to the patch nor did they suffer from precipitated withdrawal.

Discussion:

For patients that require methadone for the treatment of acute pain, the buprenorphine patch is an option to facilitate outpatient conversion back to buprenorphine. This method is best utilized as a bridge therapy due to the failure of the patch to suppress all withdrawal symptoms. The cost and need for insurance preauthorization create significant barriers to the implementation of this treatment strategy.

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2. Tang M, Lam-Shang-Leen J, Brothers T, et al. Transdermal buprenorphine to bridge to sublingual buprenorphine in hospitalized patients. Am J Addict 2019; 00:1-4.
3. Kornfeld H, Reetz H. Transdermal buprenorphine, opioid rotation to sublingual buprenorphine, and the avoidance of precipitated withdrawal: a review of the literature and demonstration in three chronic pain patients treated with Butrans. Am J Ther 2015; 22:199-205.
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