An Efficient and Smooth Methadone-to-Buprenorphine Transition Protocol Utilizing a Transdermal Fentanyl Bridge and a...

The traditional method of transitioning from methadone to buprenorphine requires a gradual dose reduction to a low dose of 30 mg daily, followed by cessation, and addressing withdrawal symptoms prior to the initiation of buprenorphine. This process can be time-consuming and is also associated with tremendous patient suffering and adverse outcomes. In recent years, several protocols have emerged based on the notion of blunting the shift from full receptor activation to partial receptor activation via an intermediate "bridge". This typically is required for the time period needed for the acting full agonist, methadone, to undergo biotransformation and clearance. In this report, we present an inadvertent case where transdermal fentanyl as a transitional bridge was utilized along with an inducer of methadone's metabolism to speed up the course, and urine acidification to enhance clearance. Our patient was transitioned from moderate-dose methadone, without encountering any withdrawal symptoms in the process, in three days. This method presents yet another option for select candidates, and it allows physicians to individualize methadone-to-buprenorphine transitions.