From the Guidelines
Transitioning a patient from oxycodone 20mg tablets 5 times/day to buprenorphine 2mg daily requires a careful approach to minimize withdrawal symptoms and ensure a smooth transition. The patient should discontinue all opioids the night before initiation, and after mild withdrawal is present, initiate 2-4 mg of buprenorphine, repeated at 2-hour intervals, if well tolerated, until resolution of withdrawal symptoms 1. Typically, 4-8 mg will be needed the first day, and the dose can be adjusted on day 2 and increased if needed. The total dose given on day 2 can then be prescribed as the daily dose. It is essential to monitor the patient for withdrawal symptoms throughout the transition and use adjunctive medications like clonidine, loperamide, or ondansetron to manage specific withdrawal symptoms if necessary.
Some key considerations when transitioning from oxycodone to buprenorphine include:
- Buprenorphine may produce acute opioid withdrawal in patients on full mu agonists, so it is crucial to wait until mild withdrawal symptoms appear before starting buprenorphine 1
- The patient should be informed about the potential for protracted withdrawal symptoms, such as dysphoria, irritability, insomnia, anhedonia, or a vague sense of being unwell, which can occur months after opioid elimination 1
- Buprenorphine has a higher receptor affinity than oxycodone but is only a partial agonist, meaning it can precipitate withdrawal if started while full opioids are still occupying receptors 1
- The entire transition process typically takes 1-2 weeks to stabilize on the appropriate buprenorphine dose, and the patient should be closely monitored for withdrawal symptoms and adverse effects throughout the transition 1
The recommended approach is to start with a low dose of buprenorphine, such as 2mg, and gradually increase the dose as needed to manage withdrawal symptoms and ensure a smooth transition. This approach is supported by the most recent and highest-quality study available, which provides guidance on buprenorphine initiation in patients taking opioids for pain 1.
From the Research
Transitioning from Oxycodone to Buprenorphine
To transition a patient from Oxycodone 20mg tablets 5 times/day to Buprenorphine 2mg daily, several factors must be considered to prevent complications such as buprenorphine precipitated opioid withdrawal (BPOW) 2.
- Assessment of Opioid Withdrawal Symptoms: It is crucial to wait for the onset of moderate Clinical Opioid Withdrawal Scale (COWS) > 13 opioid withdrawal symptoms before initiating buprenorphine administration 2.
- Timing Since Last Full Opioid Agonist Use: A sufficient amount of time should pass since the last use of a full opioid agonist like Oxycodone before starting buprenorphine to minimize the risk of BPOW 2.
- Risk Factors for BPOW: Patients with a history of chronic fentanyl use, methadone use, or concurrent benzodiazepine use are at higher risk for BPOW and should be closely monitored 2.
- Dosing Strategies for Buprenorphine: Alternative dosing strategies such as low-dose or "microdosing" and high-dose or "macrodosing" may impact the development of BPOW, and the choice of strategy should be based on the patient's patterns of opioid use and response to therapy 2.
Management of Potential Complications
In case of BPOW, management should be symptom-based and supportive, with the option of treating with more buprenorphine, which has a pharmacological basis and has been effective in case reports 2. Additionally, psychotic symptoms can occur after opioid withdrawal, and in such cases, the reintroduction of opioids might be considered to prevent further deterioration in the patient's mental status 3.
Tapering and Relapse Prevention
When considering the transition, it's also important to think about the long-term management of opioid dependence. Gradual dose tapering, as described in studies on buprenorphine taper 4, and guidelines on opioid tapering 5, can help in managing opioid dependence but may require careful planning to minimize relapse.
- Gradual Dose Tapering: A gradual outpatient buprenorphine dose taper over 28 days has been studied, showing high compliance but also a significant relapse rate, suggesting the need for a longer taper and additional support measures 4.
- Determining the Right Time to Taper: Guidelines are available to help determine when to start an opioid taper and how to do so while maintaining pain control and minimizing the risk of taper failure 5.