From the Guidelines
Transitioning a patient from 90 mg of oxycodone to buprenorphine should be done by discontinuing oxycodone and waiting until the patient is in mild withdrawal before starting buprenorphine, then initiating with 2-4 mg sublingually and titrating up as needed, as recommended by the most recent guidelines 1. To initiate this transition, the patient should discontinue all opioids, including oxycodone, the night before starting buprenorphine, allowing for the onset of mild withdrawal symptoms.
- Buprenorphine should be started at a low dose, typically 2-4 mg sublingually, and repeated at 2-hour intervals if well tolerated until resolution of withdrawal symptoms, with a total dose of 4-8 mg usually needed on the first day 1.
- The dose can be increased on subsequent days as needed, with the total dose given on day 2 often becoming the daily dose, and should be given in 3-4 daily doses for analgesia, unlike treatment for opioid use disorder. Key considerations during this transition include:
- Monitoring the patient closely for withdrawal symptoms and adjusting the buprenorphine dose accordingly
- Using adjunctive medications like clonidine, loperamide, and ondansetron to manage withdrawal symptoms as needed
- Educating the patient about the expected timeline and potential symptoms during the transition The patient's pain control and withdrawal symptoms should be closely monitored during this transition, and adjustments made as necessary to ensure effective pain management and minimize withdrawal symptoms, as buprenorphine has been shown to provide comparable pain relief with fewer adverse events compared to full opioid agonists 1.
From the Research
Transitioning from Oxycodone to Buprenorphine
To transition a patient from 90 mg of oxycodone to buprenorphine, the following steps can be considered:
- Tapering down the oxycodone dose while introducing buprenorphine, as seen in a case report where a patient was weaned from oxycodone ER 30 mg every 12 hours and oxycodone/acetaminophen 10/325 mg 3x/day for breakthrough pain 2
- Utilizing a microdosing approach to minimize pain and withdrawal, as described in a case report of a patient with sickle cell disease who transitioned from high-dose oxycodone to buprenorphine/naloxone during a hospital stay 3
- Considering the patient's individual needs and medical history, as well as the potential risks and benefits of the transition, as discussed in a retrospective clinical data analysis of 240 patients with chronic pain and long-term opioid therapy 4
Key Considerations
When transitioning a patient from oxycodone to buprenorphine, the following factors should be taken into account:
- The patient's initial dose of opioids, as higher doses may predict a higher likelihood of requiring buprenorphine transition 4
- The presence of co-occurring benzodiazepine or z-drug prescriptions, which may predict a greater likelihood of dropout from treatment 4
- The potential for withdrawal symptoms, which can be minimized with a gradual tapering approach and the use of buprenorphine 2, 3
- The importance of individualized treatment and patient-centered care, as emphasized in a case report of a patient who underwent a successful transition from oxycodone to buprenorphine 2
Pharmacological Context
Oxycodone and buprenorphine are both opioid analgesics, but they have different pharmacological properties and mechanisms of action:
- Oxycodone is a full μ-opioid receptor agonist, while buprenorphine is a partial μ-opioid receptor agonist 5, 6
- Buprenorphine has a higher affinity for the μ-opioid receptor and a longer duration of action compared to oxycodone 5
- The transition from oxycodone to buprenorphine may involve a period of overlap, during which the patient receives both medications, as described in a case report 2