From the Guidelines
The recommended protocol for transitioning a patient from 40mg/day oxycodone to sublingual buprenorphine using a low dose overlap approach involves reducing the oxycodone dose by approximately 25-50% to 20-30mg/day for 1-2 days before initiating buprenorphine, then administering a low initial dose of 2mg sublingual buprenorphine while continuing a reduced oxycodone dose. This approach is based on the most recent and highest quality study available, which emphasizes the importance of minimizing withdrawal symptoms and ensuring a smooth transition 1.
Key Considerations for Transitioning
- Reduce oxycodone dose by 25-50% to 20-30mg/day for 1-2 days before initiating buprenorphine
- Administer a low initial dose of 2mg sublingual buprenorphine while continuing a reduced oxycodone dose
- Monitor for 1-2 hours for precipitated withdrawal, and if well-tolerated, add another 2mg of buprenorphine later that day
- On day two, discontinue oxycodone completely and increase buprenorphine to 4mg twice daily
- Gradually titrate the buprenorphine dose upward over the next 3-7 days until reaching a stable maintenance dose, typically 12-16mg daily (range 8-24mg)
Rationale for the Approach
The low-dose overlap method allows buprenorphine to gradually occupy receptors while maintaining some opioid tone, reducing the risk of precipitated withdrawal that can occur with traditional induction methods 1. Buprenorphine is a partial mu-opioid agonist with high receptor affinity that can displace full agonists like oxycodone. Patients should be monitored closely for withdrawal symptoms, pain control, and side effects throughout the transition period, with dose adjustments made accordingly.
Important Considerations
- Buprenorphine may produce acute opioid withdrawal in patients on full mu agonists, and patients should be in mild opioid withdrawal before initiating buprenorphine therapy 1
- The total dose given on the first day of buprenorphine initiation can range from 4-8 mg, and the dose can be increased on subsequent days as needed 1
- Unlike treatment for opioid use disorder, buprenorphine for analgesia should be given in 3-4 daily doses 1
From the Research
Low Dose Overlap Protocol for Transitioning from Oxycodone to Buprenorphine
- The recommended protocol for transitioning a patient from 40mg/day Oxycodone to Buprenorphine using a low dose overlap protocol is not explicitly stated in the provided studies, but several principles can be applied:
- Initiating at a low buprenorphine dose and titrating gradually 2
- Continuing the full opioid agonist (in this case, oxycodone) even if it is nonmedical, while introducing buprenorphine 2
- Communicating clearly with frequent monitoring and pausing or delaying buprenorphine dose changes if opioid withdrawal symptoms occur 2
- A case report describes a patient being weaned from oxycodone ER 30 mg every 12 hours and oxycodone/acetaminophen 10/325 mg 3x/day for breakthrough pain, and then transitioned to buccal buprenorphine using an unconventional approach 3
- Another case report presents a patient with sickle cell disease who transitioned from high-dose oxycodone to buprenorphine/naloxone during a hospital stay, utilizing a microdosing approach to minimize pain and withdrawal 4
- A randomized controlled trial is being conducted to compare low-dose and standard buprenorphine initiation approaches for hospitalized patients with chronic pain and opioid use disorder or opioid misuse 5
- A 'microdosing' method for switching patients from methadone to buprenorphine has been described, which may serve as a valuable alternative to the classical approach 6
Key Considerations
- The patient's individual needs and medical history should be taken into account when developing a transition plan
- Close monitoring and frequent communication are crucial to ensure a safe and successful transition
- The use of a low dose overlap protocol may help minimize the risk of precipitated opioid withdrawal and improve patient outcomes 2, 3, 4