What is the recommended protocol for tapering off Suboxone (buprenorphine) with a switch to methadone?

Switching from Suboxone (Buprenorphine) to Methadone Protocol

The most effective protocol for transitioning from Suboxone to methadone involves discontinuing buprenorphine for 24-48 hours until moderate withdrawal symptoms appear, then initiating methadone at a low dose of 20-40mg with careful titration. 1

Why Switch from Buprenorphine to Methadone?

• Better retention rates for patients with unstable opioid use disorder
• More effective for patients who continue to use non-prescribed opioids on buprenorphine
• May provide better pain control for those with chronic pain conditions
• Appropriate for patients who have failed buprenorphine treatment 1, 2

Pre-Transition Assessment

• Verify current buprenorphine dose and duration of treatment
• Screen for benzodiazepine use (increased risk of respiratory depression with methadone)
• Check ECG for patients with cardiac risk factors (methadone can prolong QTc interval)
• Assess liver function (methadone is primarily metabolized by the liver)
• Evaluate for drug interactions that affect methadone metabolism 1

Transition Protocol

Step 1: Discontinuation of Buprenorphine

• Stop buprenorphine completely
• Wait 24-48 hours until moderate withdrawal symptoms appear (COWS score >12)
• Longer waiting periods may be needed for higher buprenorphine doses due to its long half-life 1, 3

Step 2: Initial Methadone Dosing

• Begin with 20-40mg oral methadone once withdrawal is established
• For patients on higher buprenorphine doses (>16mg/day), start at the lower end (20mg)
• For patients with lower opioid tolerance, begin with 10mg 1

Step 3: Dose Titration

• Increase dose by 5-10mg every 3-7 days based on withdrawal symptoms
• Target dose typically ranges from 60-120mg daily
• Monitor for sedation, respiratory depression, and QTc prolongation
• Stabilization usually occurs within 2-4 weeks 1

Management of Withdrawal Symptoms

During the transition period, adjunctive medications can help manage withdrawal symptoms:

• α2-Adrenergic Agonists (clonidine 0.1-0.2mg every 6 hours) for sympathetic hyperactivity
• Loperamide for gastrointestinal symptoms
• Trazodone or mirtazapine for insomnia
• NSAIDs/acetaminophen for pain and discomfort 1, 3

Alternative Approaches

Inpatient Rapid Transition

For patients requiring urgent transition, an inpatient approach using naltrexone-precipitated withdrawal followed by methadone induction can be considered, though this is more uncomfortable and requires close monitoring 4

Microdosing Method

A newer approach involves overlapping low doses of methadone while gradually reducing buprenorphine:

• Continue buprenorphine at current dose
• Start methadone at 5mg daily, increasing by 5mg every 3-4 days
• Once reaching 30-40mg of methadone, begin tapering buprenorphine
• Complete transition when methadone reaches therapeutic dose (60-80mg) 5

Monitoring and Follow-up

• Daily observed dosing at a methadone clinic initially
• Monitor for sedation, respiratory depression, and QTc prolongation
• Weekly visits during the first month of transition
• Urine drug testing to assess for continued illicit opioid use
• Adjust dose based on withdrawal symptoms, cravings, and side effects 1

Common Pitfalls to Avoid

• Initiating methadone too soon after the last buprenorphine dose can result in precipitated withdrawal
• Starting with too high a methadone dose increases risk of respiratory depression
• Inadequate monitoring during the transition period
• Failing to address underlying pain if pain management is a treatment goal
• Not preparing the patient for the more restrictive nature of methadone programs (daily observed dosing) 1, 3

Special Considerations

• Pregnancy: Methadone is well-established for use in pregnancy, though buprenorphine has advantages including less neonatal abstinence syndrome 2
• Liver disease: Dose adjustments may be needed; monitor liver function
• QTc prolongation: ECG monitoring recommended, especially with doses >100mg daily
• Polysubstance use: Increased risk of overdose with concurrent benzodiazepine or alcohol use 1

This transition protocol prioritizes patient safety while minimizing withdrawal discomfort, with the goal of maintaining treatment engagement and reducing risk of return to illicit opioid use.