What is the equivalent dose of Targin (oxycodone and naloxone) for a patient with a history of opioid dependence or chronic pain who is currently taking 800 micrograms (mcg) of buprenorphine sublingual?

Opioid Dose Conversion: 800 mcg Buprenorphine Sublingual to Targin Equivalent

For a patient on 800 mcg (0.8 mg) sublingual buprenorphine daily, there is no direct equivalent dose of Targin (oxycodone/naloxone) because this buprenorphine dose is extremely low and falls below the therapeutic range for chronic pain management—you should instead increase the buprenorphine dose to 4-16 mg daily in divided doses (every 6-8 hours) rather than switching to Targin. 1

Why This Dose is Problematic

• 800 mcg (0.8 mg) buprenorphine sublingual is far below the established therapeutic range for chronic pain, which is 4-16 mg daily divided into 8-hour doses 1
• This subtherapeutic dose explains inadequate pain control and makes conversion calculations unreliable 1

Recommended Management Algorithm

First-Line: Optimize Buprenorphine Before Switching

• Increase the buprenorphine sublingual dose in divided doses (every 6-8 hours) up to 4-16 mg daily as the primary strategy for inadequate pain control 1
• This approach leverages buprenorphine's superior safety profile, including ceiling effect on respiratory depression and lower abuse potential compared to full agonists like oxycodone 2, 1

Second-Line: Switch Buprenorphine Formulation

• Consider switching from sublingual buprenorphine/naloxone to transdermal buprenorphine patch (starting at 5-20 mcg/hour) to bypass first-pass hepatic metabolism and potentially improve analgesia 2, 1
• The transdermal formulation provides more consistent drug levels and may offer superior pain control 2

Third-Line: Add Full Agonist to Buprenorphine

• If maximal buprenorphine dosing (16 mg daily or 140 mcg/hour transdermal) provides inadequate analgesia, add a long-acting potent opioid such as extended-release oxycodone (the active component of Targin), fentanyl, morphine, or hydromorphone 1
• Be aware that higher doses of the additional opioid will be required due to buprenorphine's high binding affinity blocking other opioids from accessing mu-receptors 1

Fourth-Line: Transition to Methadone

• For patients with persistent inadequate analgesia despite all above strategies, transition from buprenorphine to methadone maintenance 1

If You Must Calculate a Conversion (Not Recommended at This Dose)

Theoretical Conversion Calculation

• Buprenorphine sublingual has approximately 30-40% bioavailability and is roughly 40-100 times more potent than oral morphine on a milligram-per-milligram basis 3, 4
• 0.8 mg sublingual buprenorphine ≈ 32-80 mg oral morphine equivalent (using conservative 40:1 ratio)
• Oral oxycodone is approximately 1.5 times more potent than oral morphine 5
• This translates to approximately 20-55 mg oral oxycodone daily

Critical Conversion Pitfalls

• Apply a 25-50% dose reduction when switching opioids due to incomplete cross-tolerance 2
• Patients previously on morphine, oxycodone, and fentanyl had the greatest success (2.5-3.7 point pain reduction) when converting TO buprenorphine, suggesting these conversions work better in that direction 4
• Patients on very low baseline opioid doses (≤20 mg morphine equivalent) experienced early adverse events when switched to buprenorphine, indicating bidirectional conversion challenges at low doses 6

Managing Breakthrough Pain During Transition

• Continue baseline buprenorphine during acute pain episodes—do not discontinue 5, 7
• Use adjuvant therapies appropriate to pain type: gabapentin for neuropathic pain, NSAIDs for inflammatory/musculoskeletal pain, topical agents as indicated 5, 1
• If opioid rescue is needed, use high-potency agents like hydromorphone or fentanyl, recognizing higher doses may be required due to buprenorphine's receptor occupancy 2
• Avoid mixed agonist-antagonist opioids (pentazocine, nalbuphine) as they may precipitate acute withdrawal syndrome 5, 2

Special Considerations for This Patient

• Verify if this patient is on buprenorphine for opioid use disorder (OUD) versus chronic pain—sublingual formulations are FDA-approved for OUD, while transdermal patches are approved for chronic pain 7
• If the patient has OUD and now requires pain management, the first step is increasing sublingual buprenorphine dose in divided doses rather than switching to Targin 5, 1
• Screen for depression and mental health conditions before finalizing long-term opioid therapy, as these significantly impact pain outcomes and substance use risk 2, 1

Why Targin May Not Be the Right Choice

• Buprenorphine has superior safety compared to oxycodone: lower respiratory depression risk, reduced abuse potential, and no dose adjustment needed in renal impairment 2, 1
• Systematic reviews confirm buprenorphine provides comparable pain relief to full agonists with fewer adverse events 2
• Patients on moderate opioid doses (100-199 mg morphine equivalent) had the greatest pain reduction (2.7 points) when converting TO buprenorphine, while those on very high doses (>400 mg) had minimal benefit 4