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JCosta - (8/16/2017 8:44:09 AM)
August 2017: Beginning a buprenorphine MAT program
Question: Our jail is beginning a buprenorphine MAT program. My question is what should we do about individuals who are already on a methadone maintenance program when they are incarcerated? We won’t be offering methadone. Can they be switched if they choose?

Answer: Individuals with opioid use disorders can safely be switched from methadone to buprenorphine maintenance. According to SAMHSA Quick Guide for Physicians, Clinical Guidelines for the Use of Buprenorphine in the treatment of Opioid Addiction, “Appropriate dosages of buprenorphine are more effective than low dosages (20–35 mg) of methadone. A buprenorphine dosage of 8–16 mg/day is equivalent to about 60 mg/day of methadone.” However, the Guide advises: “Induction of patients from long-acting opioids (e.g., methadone) onto buprenorphine should be managed by physicians experienced with the procedure. Patients taking methadone should have their dose tapered to 30 mg or less per day for at least 1 week before buprenorphine induction. Twenty-four hours must elapse between the final dose of methadone and the first dose of buprenorphine. The first dose of buprenorphine should be 2 mg of monotherapy. A second 2 mg dose can be given and repeated up to 8 mg per day if signs of withdrawal appear.” The Guide goes on to chart the steps in the induction from day 2 and forward. When the person as no withdrawal symptoms, minimal side effects and no uncontrollable cravings, he or she is considered stabilized. During stabilization (1 to 2 months), adjustments in dosage and frequent physician–patient contact establish the proper level of medication. Until full stabilization is achieved, weekly assessments are indicated. Doses of buprenorphine/naloxone may be increased in 2/0.5–4/1 mg increments until stabilization is achieved. Nearly all patients stabilize on daily doses of 16/4–24/6 mg; some may require up to 32/8 mg daily. The maintenance phase follows.

Second Answer: The American Society of Addiction Medicine has guidelines for switching. ASAM Practice Guideline Highlights ASAM Practice Guideline Highlights

Part 4 – Methadone
(9) Patients switching from methadone to buprenorphine in the treatment of opioid use disorder should be on low doses of methadone before 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.

Part 5 – Buprenorphine
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. Buprenorphine doses after induction and titration should be, on average, at least 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 US 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.

Part 12 - Special Populations: Individuals in the Criminal Justice System
(1) Pharmacotherapy for the continued treatment of opioid use disorders, or the initiation of pharmacotherapy, has been shown to be effective and is recommended for prisoners and parolees regardless of the length of their sentenced term.

(2) Individuals with opioid use disorder who are within the criminal justice system should be treated with some type of pharmacotherapy in addition to psychosocial treatment.

(3) Opioid agonists (methadone and buprenorphine) and antagonists (naltrexone) may be considered for treatment. There is insufficient evidence to recommend any one treatment as superior to another for prisoners or parolees.

(4) Pharmacotherapy should be initiated a minimum of 30 days before release from prison.

Third Answer: Wanted to inform the questioner that the decision to substitute buprenorphine for methadone has both merit and demerits.

An examination of 31 randomized clinical trials involving more than 5,000 participants that compared those on methadone and those on buprenorphine, with or without naloxone, and those receiving a placebo found that buprenorphine was effective at retaining persons in treatment at any dose above 2 mg and was effective at suppressing illicit opioid use at doses equivalent to 16 mg or greater. However, buprenorphine at low fixed doses or flexibly delivered was not as effective as methadone at retaining patients in treatment. If fixed medium or high doses are used, buprenorphine and methadone appear no different in effectiveness (retention in treatment and suppression of illicit opioid use); however, fixed doses are rarely used in clinical practice so the flexible dose results are more relevant to patient care. Methadone is superior to buprenorphine in retaining people in treatment, and methadone equally suppresses illicit opioid use. (Mattick, R.P. et al (2014). Buprenorphine maintenance versus placebo or methadone maintenance for opioid dependence, Cochrane Database of Systemic Reviews 201(2), i-84. Doi:10.1002/14651858.CD002207.pub4)

Other studies have found that buprenorphine maintenance is more effective than short-term buprenorphine treatment followed by medication tapering in terms of both patient retention and rate of relapse to opioid use. Even after 12 weeks of buprenorphine, tapering has been found to be associated with very high relapse rates (90% after 8 weeks).

On the other hand, buprenorphine is safer than full agonist medications like methadone because of its relatively poor bioavailability and its ceiling effect. The ceiling effect means that as the buprenorphine doses increases, its effects increase only to a point, meaning the effects no longer increase even as the doses are increased. This ceiling effect also means that it carriers lower risk of misuse, dependence, and side effects than full agonists. There is still some risk of overdose particularly if mixed with other opiates, benzodiazepines, alcohol, sedatives or certain medications that interact with buprenorphine. There appear to be fewer potential interactions between buprenorphine and antiretrovirals (used for HIV) than between methadone and antiretrovirals. There also appear to be no significant interactions between buprenorphine and most hep C virus medications. More information on buprenorphine interaction with other medications can be found on a SAMHSA Advisory, Sublingual and Transmucosal Buprenorphine for Opioid Use Disorder: Review and Update, 2016.