How do I transition a patient with chronic pain and opioid use disorder from transdermal fentanyl to buprenorphine?

Transitioning from Transdermal Fentanyl to Buprenorphine for Chronic Pain and Opioid Use Disorder

The most effective approach for transitioning a patient from 50 μg transdermal fentanyl to buprenorphine is to use a micro-induction protocol that allows for gradual introduction of buprenorphine without requiring complete discontinuation of fentanyl first. 1

Understanding the Challenge

Transitioning from a full opioid agonist like fentanyl to a partial agonist like buprenorphine presents unique challenges:

• Buprenorphine has high affinity for μ-opioid receptors but lower intrinsic activity
• Traditional induction methods require patients to be in withdrawal before starting buprenorphine
• Precipitated withdrawal is a significant risk if buprenorphine is started too early
• Fentanyl's lipophilicity means it can remain in tissues for extended periods after patch removal

Micro-Induction Protocol for Outpatient Setting

Day 1:

• Continue 50 μg fentanyl patch
• Start buprenorphine at 0.5 mg SL twice daily
• Provide adjunctive medications as needed:
  • Clonidine 0.1 mg every 6 hours PRN for autonomic symptoms
  • Ondansetron 4 mg every 6 hours PRN for nausea
  • Loperamide 2 mg PRN for diarrhea

Day 2:

• Continue fentanyl patch
• Increase buprenorphine to 1 mg SL three times daily
• Continue adjunctive medications as needed

Day 3:

• Continue fentanyl patch
• Increase buprenorphine to 2 mg SL three times daily
• Continue adjunctive medications as needed

Day 4:

• Remove fentanyl patch
• Increase buprenorphine to 4 mg SL three times daily
• Continue adjunctive medications as needed

Day 5:

• Increase buprenorphine to 8 mg SL twice daily or 16 mg once daily
• Titrate to optimal dose for both pain control and OUD management

Monitoring During Transition

• Assess for signs of precipitated withdrawal using the Clinical Opiate Withdrawal Scale (COWS)
• Monitor for adequate pain control
• Evaluate for sedation or respiratory depression
• Schedule frequent follow-up visits during the transition period

Special Considerations

1. Dual Treatment Goals: The approach must address both chronic pain and opioid use disorder 2

   • Buprenorphine dosing for pain management may require divided doses (every 6-8 hours)
   • Dosing ranges of 4-16 mg divided into 8-hour doses have shown benefit for chronic pain

2. Formulation Selection:

   • For patients with both pain and OUD, consider buprenorphine without naloxone for better pain control 2
   • Transdermal buprenorphine may be considered as an alternative to sublingual formulations

3. Potential Pitfalls:

   • Inadequate dosing leading to withdrawal or pain
   • Precipitated withdrawal if traditional induction methods are used
   • Undertreatment of pain due to ceiling effect of buprenorphine
   • Overestimation of equivalent dosing

Alternative Approaches

If the micro-induction protocol is not feasible or unsuccessful:

1. Short-Acting Opioid Bridge Method 3:

   • Taper fentanyl patch to lowest dose
   • Discontinue fentanyl and introduce short-acting opioid (e.g., hydromorphone)
   • After 24-48 hours on short-acting opioid, discontinue and wait for mild withdrawal
   • Begin buprenorphine induction at 2-4 mg, titrating up as tolerated

2. Inpatient Transition for complex cases:

   • Consider inpatient admission for closely monitored transition
   • May be necessary for patients with high-dose requirements or medical comorbidities
   • Allows for more aggressive symptom management during transition

3. Methadone Alternative:

   • If transition to buprenorphine proves too difficult, consider methadone as an alternative 2
   • Methadone can be effective for both pain management and OUD
   • Requires careful QTc monitoring and dose titration

Long-Term Management

Once stabilized on buprenorphine:

• For ongoing pain management, consider divided dosing (every 6-8 hours) 2
• Target dose range of 4-16 mg daily in divided doses for chronic pain
• Monitor for continued substance use disorder symptoms
• Implement multimodal pain management strategies including non-opioid analgesics and non-pharmacological approaches

The rapid micro-induction approach minimizes patient discomfort while maximizing the chances of successful transition from fentanyl to buprenorphine, addressing both the patient's chronic pain and opioid use disorder.