Can a patient be switched from Suboxone (buprenorphine/naloxone) to methadone on the same day?

From the Guidelines

It is not recommended to switch a patient from Suboxone to methadone on the same day, as this can precipitate withdrawal symptoms or inadequate pain control. According to the most recent evidence [ 1 ], switching from buprenorphine to methadone can be done immediately in the absence of sedation, but this is not a standard recommendation for all patients.

Key Considerations

• The presence of sedation is a critical factor in determining the safety of switching from buprenorphine to methadone [ 1 ].
• Patients should be closely monitored for withdrawal symptoms and side effects when transitioning from one medication to another.
• The long half-life of methadone (24-36 hours) means it accumulates in the body, so dose adjustments should be made no more frequently than every 3-5 days [ 1 ].

Transitioning from Suboxone to Methadone

• When initiating methadone, start with a low dose (typically 20-30mg) and titrate slowly under medical supervision [ 1 ].
• The transition should always be supervised by healthcare providers experienced in addiction medicine, preferably in a controlled setting where the patient can be monitored for withdrawal symptoms, side effects, and proper dosing.
• It is essential to consider the individual patient's needs and medical history when making decisions about medication transitions [ 1 ].

From the FDA Drug Label

Methadone differs from many other opioid agonists in several important ways. Methadone's pharmacokinetic properties, coupled with high interpatient variability in its absorption, metabolism, and relative analgesic potency, necessitate a cautious and highly individualized approach to prescribing Particular vigilance is necessary during treatment initiation, during conversion from one opioid to another, and during dose titration. The initial methadone dose should be administered, under supervision, when there are no signs of sedation or intoxication, and the patient shows symptoms of withdrawal. If same-day dosing adjustments are to be made, the patient should be asked to wait 2 to 4 hours for further evaluation, when peak levels have been reached.

The patient can be switched from Suboxone to methadone on the same day, but with caution and under supervision. The initial dose of methadone should be administered when the patient shows symptoms of withdrawal and there are no signs of sedation or intoxication. Same-day dosing adjustments can be made, but the patient should be asked to wait 2 to 4 hours for further evaluation, when peak levels have been reached 2. Key considerations include:

• Individualized approach to prescribing methadone
• Particular vigilance during treatment initiation and conversion from one opioid to another
• Supervision during initial dosing and same-day dosing adjustments
• Cautious dose adjustments to avoid cumulative effects and overdose risk.

From the Research

Switching from Suboxone to Methadone

• The decision to switch a patient from Suboxone (buprenorphine-naloxone) to methadone should be based on individual patient characteristics and preferences 3.
• Methadone is preferred over buprenorphine-naloxone for patients at higher risk of treatment dropout, such as injection opioid users 3.
• If buprenorphine-naloxone is prescribed first, the patient should be promptly switched to methadone if withdrawal symptoms, cravings, or opioid use persist despite an optimal buprenorphine-naloxone dose 3.
• There is no direct evidence to suggest that switching from Suboxone to methadone can be done on the same day, but studies have shown that transfer from methadone to buprenorphine can be done successfully with careful planning and monitoring 4.

Considerations for Switching

• The transfer protocol from methadone to buprenorphine is extremely varied, and most studies reported successful rates of transfer, even among studies involving transfer from high methadone doses 4.
• Lower pretransfer methadone dose was significantly associated with higher rate of successful transfer 4.
• Precipitated withdrawal was not reported frequently in studies of transfer from methadone to buprenorphine 4.
• The severity of toxicity associated with nonmedical use of benzodiazepines with buprenorphine or methadone should be considered when making the decision to switch 5.

Clinical Outcomes

• Methadone and buprenorphine-naloxone have comparable outcomes during rapid outpatient stabilisation and detoxification in low dose opiate users 6.
• Methadone has higher treatment retention rates than buprenorphine-naloxone, while buprenorphine-naloxone has a lower risk of overdose 3.
• Nonmedical use of benzodiazepines with methadone is associated with higher hospitalization rates, greater ICU utilization rates, and considerably worse medical outcomes when compared to nonmedical use of benzodiazepines with buprenorphine 5.