(52) Accelerated Inpatient Transition from Methadone to Long-Acting Injectable Buprenorphine

Background & Introduction: Eighty-eight percent of the more than 106,000 drug overdoses in the US in 2021 were associated with opioid use. Current Food and Drug Administration-approved medications for opioid use disorder (OUD) include methadone, buprenorphine, and extended-release naltrexone. While methadone is an evidence-based treatment for OUD, many patients experience barriers such as the required daily clinic attendance, limited clinic hours, transportation, limits to dose titration, and stigma. Patients who miss their methadone doses may be required to re-initiate methadone at a starting dose, which may destabilize their OUD treatment. Some patients may also have medical conditions, including cardiac disease, that preclude the use of methadone.

For these reasons, certain patients may benefit from transitioning from methadone to buprenorphine. However, methadone’s long half-life creates challenges for transitions to buprenorphine while avoiding precipitated withdrawal. There are few studies that describe an "optimal" transfer strategy from methadone to buprenorphine. Hospitalization may present an opportunity to transition patients in a more controlled setting. Long-acting injectable buprenorphine (LAIB) represents an additional opportunity to address patient barriers to adherence. With these cases, we demonstrate that an accelerated transition from methadone to LAIB is feasible using advanced buprenorphine techniques and may be an option for select hospitalized patients.

Methods: Patients were selected for the accelerated transition from methadone to LAIB based on a history of OUD, history of stable outpatient methadone treatment, and the desire to transition from methadone maintenance therapy to LAIB. Patients were also admitted due to separate medical issues and thus were able to be monitored inpatient. Patient consent was obtained and the risks of precipitated opioid withdrawal were reviewed. Patients were monitored for signs of opioid withdrawal during this transition and their symptoms were treated accordingly. They were scheduled for outpatient follow up with the addiction medicine clinic to continue their monthly LAIB. Patient consent was obtained to participate in this study. IRB exemption was also obtained for these case studies.

Results: Patient #1 successfully transitioned from methadone to LAIB using an accelerated approach using a 24-hour IV buprenorphine infusion with adjunctive full opioid agonists, as detailed below. He received LAIB on hospital day 2. Patient #2 also successfully transitioned from methadone to LAIB using an accelerated approach using a faster rate of IV buprenorphine infusion and received LAIB on hospital day 1, as detailed below.

Case Description: Project LIFE (Long-Acting Injectable Buprenorphine to End Overdose) is a hospital-based LAIB program that was started at the West Suburban Medical Center (WSMC) in Chicago, Illinois in August 2022. It allows patients to initiate LAIB in the emergency room and inpatient setting. Patients are then offered clinic follow-up to continue treatment. We present the cases of two patients who transitioned from methadone to LAIB during their hospitalization at WSMC using an accelerated approach. All patients provided consent.

Patient #1 is a 62-year-old African American male with a past medical history of untreated HIV, cocaine use, severe OUD on methadone 100mg daily with ongoing intermittent heroin use who presented with nausea, vomiting, myalgias, generalized weakness, and opioid withdrawal. He was admitted for renal insufficiency, anemia, and hypertension. He wanted to transfer from methadone to LAIB due to difficulty attending daily clinic visits. He consented to an accelerated transition using low-dose IV buprenorphine with full agonist therapy and acknowledged the risks of precipitated withdrawal. 3.6mg of IV buprenorphine was administered via a continuous IV infusion over 24 hours (0.15mg/hour), with oxycodone 10mg every 4 hours and adjunctive withdrawal medications. LAIB was administered on hospital day 2. No precipitated withdrawal occurred. He experienced mild gastrointestinal-related withdrawal symptoms controlled with ondansetron. He has continued to follow up regularly at the addiction medicine clinic for monthly LAIB.

Patient #2 is a 54-year-old African American female with a past medical history of intermittent cocaine use and severe OUD who presented to the WSMC Emergency Department with acute respiratory failure requiring BiPAP support and severe opioid withdrawal with a COWS of 12. She was admitted for a COPD exacerbation and pneumonia. She was on 70mg of methadone daily, which she received the day prior to admission. She expressed the desire to transition to LAIB due to frustration with her opioid treatment program rules and consented to an accelerated, high-dose buprenorphine initiation after risks and benefits were discussed. She received 2.1mg of IV buprenorphine over one hour for the management of severe opioid withdrawal, 1mg of IV dilaudid, and 1mg of lorazepam. LAIB was administered after the IV buprenorphine infusion. Her ongoing withdrawal symptoms were controlled with as-needed clonidine, dicyclomine, and 20mg oxycodone every 4 hours for 24 hours, with significant improvement. She has continued to follow up at the addiction medicine clinic and receive monthly LAIB.

Conclusion & Discussion: The transition from methadone to LAIB can be accomplished using advanced buprenorphine techniques that include low-dose and high-dose IV buprenorphine with full opioid agonist medications. Patient consent should be obtained and the risk of precipitated withdrawal should be reviewed prior to initiation of buprenorphine products. Ultimately, these techniques require further study, but our case studies illustrate the possibility of successfully transitioning patients from methadone to LAIB in the inpatient setting. However, limitations do exist - few hospitals have addiction medicine consult services, IV buprenorphine is not on the formulary for many facilities and it is also difficult to get LAIB in hospitals.

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