Abstract
Methadone, a full opioid agonist at the mu-, kappa-, and delta-receptor, and buprenorphine, a partial agonist at the mu receptor, are first-line medications in opioid maintenance treatment. Transition from methadone to buprenorphine may precipitate withdrawal, and no accepted algorithm for this procedure has been developed. Current treatment strategies recommend transfer from methadone to buprenorphine predominantly in patients at low doses of methadone (30–40 mg/day). There are some reports indicating that transition from higher doses of methadone may be possible. A number of dosing strategies have been proposed to soften withdrawal symptoms and facilitate transfer including use of other opioids or medications and especially microdosing techniques for buprenorphine. The case series and studies available thus far are reviewed.
Highlights
Opioid dependence is a chronic relapsing disorder causing enourmous social and economic harm (Degenhardt et al, 2014; Neusser et al, 2020)
Major advantages of buprenorphine are the lesser risk for respiratory depression, less severe withdrawal symptoms upon discontinution, and the chance of alternate-day dosing (Mattick et al, 2014; Kimber et al, 2015; Sordo et al, 2017; Soyka et al, 2017; Bell and Strang, 2020), and possibly a greater reduction of opioid use in patients with comorbid mental disorders compared to methadone (Hser et al, 2021)
A “rapid transition” approach was suggested by Ward et al (2019) who reported the case of a patient on methadone 65 mg who was given naltrexone, soon followed by buprenorphine induction
Summary
Specialty section: This article was submitted to Neuropharmacology, a section of the journal Frontiers in Pharmacology. A full opioid agonist at the mu-, kappa-, and delta-receptor, and buprenorphine, a partial agonist at the mu receptor, are first-line medications in opioid maintenance treatment. Transition from methadone to buprenorphine may precipitate withdrawal, and no accepted algorithm for this procedure has been developed. Current treatment strategies recommend transfer from methadone to buprenorphine predominantly in patients at low doses of methadone (30–40 mg/day). There are some reports indicating that transition from higher doses of methadone may be possible. A number of dosing strategies have been proposed to soften withdrawal symptoms and facilitate transfer including use of other opioids or medications and especially microdosing techniques for buprenorphine. The case series and studies available far are reviewed
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