Microdosing Transdermal Buprenorphine to Transition a Patient off a Higher-Dose Methadone Regimen

A patient taking high-dose methadone successfully transitioned to buprenorphine using a transdermal microdosing protocol that did not require prior methadone dose tapering and avoided opioid withdrawal symptoms. The protocol included an as-needed full opioid agonist. This case suggests that microinduction can remove the prerequisite of moderate withdrawal typically needed for buprenorphine initiation, though further research is needed to define optimal protocols, especially for patients on methadone or using illicit fentanyl.

Study at a glance

Abstract

Abstract Background Buprenorphine is a partial µ-opioid agonist with high receptor binding affinity and long half-life—qualities that reduce overdose risk with concomitant opioid use, though may precipitate withdrawal by displacing full agonists. Traditional buprenorphine induction typically requires patients endure moderate withdrawal prior to initiation, with challenges intensifying for patients transitioning from higher-dose methadone. Novel microinduction reports aim to remove this prerequisite, though with significant limitations. Methods Case report (n=1). Results Our patient taking high-dose methadone transitioned to buprenorphine using a transdermal microdosing protocol with an as needed full opioid agonist that did not require methadone dose tapering prior to initiation and avoided symptoms of opioid withdrawal. Conclusions Further research is needed to define optimal microdosing protocols, especially for patients on methadone and/or using illicit fentanyl.