Failed transition to buprenorphine extended-release injection from high-dose methadone

Symptoms of opioid withdrawal with buprenorphine inductions pose significant challenges when trying to transition a patient from a full agonist opioid. There are numerous strategies to reduce the risk including traditional induction, microdosing, and macrodosing. Whereas there is an abundance of literature on successful strategies, there is limited literature on risk factors that identify those who are likely to fail transition to buprenorphine and should be cautioned. We present a case of a 43-year-old male on high-dose methadone who was rapidly transitioned to buprenorphine. He experienced significant withdrawal symptoms, resulting in hospitalization, multiple relapses, and suicidal ideation. He was ultimately transitioned back to methadone and restabilized. The primary factors likely resulting in this treatment failure are high-dose opioid use prior to transition, rapid transition, and patient reluctance to transition at time of buprenorphine initiation.