ASAM Provider Guide

7 Î Switching from methadone to another medication for the treatment of OUD may be appropriate if the patient experiences intolerable side effects or is not successful in attaining or maintaining treatment goals through the use of methadone. Î Patients switching from methadone to buprenorphine in the treatment of OUD should be on low doses of methadone prior to switching medications. • Patients on low doses of methadone (30–40 mg per day or less) generally tolerate transition to buprenorphine with minimal discomfort, whereas patients on higher doses of methadone may experience significant discomfort in switching medications. Î Patients switching from methadone to oral naltrexone or extended- release injectable naltrexone must be completely withdrawn from methadone and other opioids, before they can receive naltrexone. • The only exception would apply when an experienced clinician receives consent from the patient to embark on a plan of naltrexone-facilitated opioid withdrawal management. Î Patients who discontinue agonist therapy with methadone or buprenorphine and then resume opioid use should be made aware of the risks associated with opioid overdose, and especially the increased risk of death. Buprenorphine Î Opioid-dependent patients should wait until they are experiencing mild to moderate opioid withdrawal before taking the first dose of buprenorphine to reduce the risk of precipitated withdrawal. • Generally, buprenorphine initiation should occur at least 6–12 hours after the last use of heroin or other short-acting opioids, or 24–72 hours after their last use of long-acting opioids such as methadone. Î Induction of buprenorphine should start with a dose of 2–4 mg. Dosages may be increased in increments of 2–4 mg. Î Clinicians should observe patients in their offices during induction. However, home buprenorphine induction may be considered. • Home-based induction is recommended only if the patient or prescribing physician is experienced with the use of buprenorphine. Î Buprenorphine doses after induction and titration should be, on average, ≥8 mg per day. However, if patients are continuing to use opioids, consideration should be given to increasing the dose by 4–8 mg (daily doses of 12–16 mg or higher). • The FDA approves dosing to a limit of 24 mg per day, and there is limited evidence regarding the relative efficacy of higher doses. In addition, the use of higher doses may increase the risk of diversion. Î Psychosocial treatment should be implemented in conjunction with the use of buprenorphine in the treatment of OUD.

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