Patients who are Dependent on Methadone

You can often transfer stable methadone patients to buprenorphine. However, you should investigate the patient's motivation to change treatments before switching him/her to buprenorphine.

Note that stable patients on methadone doses >100 may not always be good candidates for buprenorphine since induction will require destabilizing their recovery for a period of time while they taper down to a lower methadone dose. Also, some methadone patients may not be able to reach a level of comfort on buprenorphine that a full agonist provides.

Common reasons a patient may request a transfer from methadone to buprenorphine include:

  • Patient lives far from methadone clinic and/or wants less frequent dosing visits
  • Patient can not get a job due to scheduling issues and required daily clinic visits
  • Patient is not doing well on methadone - experiencing side effects or drug cravings
  • Patient perceives stigma associated with methadone
  • Patient no longer wants to receive treatment from an opioid treatment program
  • Patient health insurance will not cover the cost of methadone.

Follow these guidelines when transferring a patient from methadone to buprenorphine:

  • Make sure the patient is stable and the risk of relapse to opioids is low before agreeing to transfer to buprenorphine.
  • Work closely with patients to ensure that they have a good understanding of what the transfer entails and that they are willing and able to go through this transition.
  • Work closely with the patient's methadone provider this is key to a successful transfer.
  • Ensure that the patient has the financial resources (health insurance or otherwise) to cover the cost of buprenorphine treatment.
  • Have the patient taper his/her dose of methadone to around 30-40mg before starting buprenorphine treatment, and maintain this level for a week. This can cause discomfort for patients on high doses of methadone (60-100mg), but is necessary to avoid precipitated withdrawal during buprenorphine induction.
  • Start buprenorphine induction 48-72 hours after the last dose of methadone. Observe for signs of withdrawal prior to induction, since a smooth transition depends on the patient being in the beginning stages of withdrawal. Note that patients seem to reach withdrawal at different times and many can take days to get there; support and guidance are critical to avoid a relapse.
  • Begin induction with a 2 mg dose of buprenorphine. Clinical experience has shown that full stabilization will take longer for individuals taking methadone than for those taking short-acting opioids, so adjunctive medications such as clonidine, NSAIDS, and hypnotics such as zolpidem may prove helpful during this process.
  • Remember that patients can always be placed back on methadone if they do not tolerate buprenorphine. Check with the patient's methadone clinic and be sure the patient can return if needed, that there is not a waiting period for restarting treatment, and what other rules they have for returning to treatment.


Related Resources: 
PCSS-B Guidance: Transfer from Methadone to Buprenorphine
Description: 
Document written to assist physicians in deciding which patients receiving methadone are good candidates for transfer to buprenorphine, and how to go about making this transition.
Source: 
Physician Clinical Support System (PCSS)
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Supplemental Case Studies
Description: 
These case studies are intended to serve as a supplement to the buprenorphine training. Areas covered include: patient assessment, induction, and maintenance. These cases can be used free of charge.
Source: 
Clinical Tools, Inc.
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Transfer from Methadone Form
Description: 
This form provides a list of important considerations when determining whether a methadone patient is a candidate for transfer to buprenorphine treatment, including social, medical, and psychiatric history.
Source: 
Colleen LaBelle, RN/Boston Medical Center
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Methadone and Buprenorphine for the Management of Opioid Dependence
Description: 
A systematic review and economic evaluation of methadone and buprenorphine for the management of opioid dependence.
Source: 
Health Technology Assessment; Vol 11: number 9. Connock et al., 2007.
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