Transdermal Low-Dose Buprenorphine Induction to Transition a Patient off a Higher-Dose Methadone Regimen: a Case Report

Buprenorphine is a partial μ‐opioid agonist with high receptor binding affinity and long half-life—qualities that reduce overdose risk with concomitant opioid use, though may precipitate withdrawal by displacing full agonists. Traditional buprenorphine induction typically requires patients endure moderate withdrawal prior to initiation, with challenges intensifying for patients transitioning from higher-dose methadone. Novel low-dose inductions aim to remove this prerequisite, though with significant limitations. We present a case of transdermal low-dose buprenorphine induction for a patient on 150 mg methadone who had ongoing fentanyl use and acute surgical pain. Our patient taking high-dose methadone transitioned to buprenorphine using a transdermal low-dose initiation protocol with an as needed full opioid agonist that did not require methadone dose tapering prior to initiation and avoided symptoms of opioid withdrawal. This report adds to a growing literature supporting the use of transdermal low-dose buprenorphine induction, especially for patients on methadone and other full opioid agonists. Further research is needed to define optimal low-dose buprenorphine induction protocols, especially for patients on methadone and/or using illicit fentanyl.