High-Dose Buprenorphine Initiation to Rapidly Transition From High-Dose Methadone in the Hospital

Transitions from high-dose methadone to buprenorphine remain challenging, and the evidence base for high-dose buprenorphine initiation (HDBI) strategies in this context is limited. We reviewed the published literature on HDBI with a particular focus on their application for patients maintained on methadone and identified no prior reports of successful transition from methadone doses as high as 180 mg. We then describe a hospitalized patient who underwent a safe and effective transition from 180 mg of methadone to buprenorphine through a high-dose initiation protocol with support of adjunctive medications. The patient stabilized within 1 week on 32 mg of buprenorphine daily and later on monthly long-acting buprenorphine. This case adds to the evidence that HDBI may offer a feasible and clinically valuable approach for transitioning patients from high-dose methadone during the inpatient setting, where close monitoring and supportive care can be provided.