This document outlines a 6-week outpatient protocol for converting patients dependent on high-dose methadone to buprenorphine. [1] It involves 7 meetings over 6 weeks where the patient is gradually converted from methadone to morphine sulfate and then inducted onto and stabilized on buprenorphine. [2] Gabapentin is prescribed to help manage withdrawal symptoms during the conversion process. [3] Behavioral health support is also an important part of the protocol.

1.
Complex Persistent Dependency Patients
High Dose Methadone to Buprenorphine Conversion
6wk Outpatient Protocol
1. Meeting #1 (D1)Discuss conversion.
Load with gabapentin to 1200mg/d over next 28d.
a. Sign material risk/Tx agreement
b. Refer to behavioral health (BH).
c. Check EKG for QTc
d. If male pt. check testosterone level
e. Prescribe nasal naloxone
f. Obtain UDS/SDS
2. Meeting #2 (D8) Agree to refill 7d dose of existing meds.
a. Train spouse/SO in nasal naloxone admin
3. Meeting #3 (D15) Conversion to morphine sulfate ER.
1​
Methadone 50mg/day = Morphine Sulfate IR 30mg po TID
Methadone 75mg/day = Morphine Sulfate IR 30mg po QID
Methadone 100mg/day = Morphine Sulfate IR 45mg po TID + 15mg ER QD
Methadone 120mg/day = Morphine Sulfate IR 45mg po QID
a. Give 7d supply of MS04 & schedule weekly f/u visits.
b. Start a 7d supply of clonidine
c. Engage Behavioral Health (BH) for support
4. Meeting #4 (D22) Refill/recheck/adjust.
a. Give 6.5d supply of opioid & schedule 7d f/u
b. Rx another 7d supply of clonidine, hydroxyzine, relafen, chlordiazepoxide.
c. D/W BH
5. Meeting #5 (D29) Buprenorphine Induction
a. Obtain SDS/UDS
6. Meeting #6 (D36) Buprenorphine Stabilization
7. Meeting #7 (D43) Buprenorphine Maintenance
1.
Practical Pain Management Calculator: http://opioidcalculator.practicalpainmanagement.com/disclaimer.php

2. References:
1. Vital Signs: Risk for Overdose from Methadone Used for Pain Relief — United States,
1999–2010 Weekly July 6, 2012 / 61(26);493­497:
http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6126a5.htm?s_cid=mm6126a5_w
2. Opioid Dependence vs Addiction: A Distinction Without a Difference?​ Ballantyne JC,
Sullivan MD, Kolodny A.Arch Intern Med. 2012 Sep 24;172(17):1342­3.
3. J Subst Abuse Treat.​ 2014 Aug;47(2):140­5. doi: 10.1016/j.jsat.2014.03.004. Epub 2014
Apr Reasons for opioid use among patients with dependence on prescription opioids: the
role of chronic pain. ​Weiss RD​1, ​Potter JS​2, ​Griffin ML​3, ​McHugh RK​3, ​Haller D​4,
Jacobs P​5, ​Gardin J 2nd​6, ​Fischer D​7, ​Rosen KD​.
4. Pain Med.​ 2014 Dec;15(12):2087­94. doi: 10.1111/pme.12520. Epub 2014 Sep 12.
Conversion from high­dose full­opioid agonists to sublingual buprenorphine reduces pain
scores and improves quality of life for chronic pain patients. ​Daitch D​1, ​Daitch J​,
Novinson D​, ​Frey M​, ​Mitnick C​, ​Pergolizzi J Jr​.
5. JAMA.​ 2003 May 14;289(18):2370­8. Prevalence and characteristics of chronic pain
among chemically dependent patients in methadone maintenance and residential
treatment facilities. ​Rosenblum A​1, ​Joseph H​, ​Fong C​, ​Kipnis S​, ​Cleland C​, ​Portenoy
RK​.
6. J Pain.​ 2015 Sep;16(9):887­94. doi: 10.1016/j.jpain.2015.06.003. Epub 2015 Jun 21.
Pain Among High­Risk Patients on Methadone Maintenance Treatment. ​Voon P​1,
Hayashi K​2, ​Milloy MJ​3, ​Nguyen P​2, ​Wood E​3, ​Montaner J​3, ​Kerr T​4.
7. Drug Alcohol Depend.​ 2010 Jun 1;109(1­3):213­9. doi:
10.1016/j.drugalcdep.2010.01.006. Epub 2010 Feb 16. Gabapentin improves
cold­pressor pain responses in methadone­maintained patients. ​Compton P​1, ​Kehoe P​,
Sinha K​, ​Torrington MA​, ​Ling W​.
8. Pain.​ 2005 Nov;118(1­2):15­22. Epub 2005 Sep 9.Different profiles of
buprenorphine­induced analgesia and antihyperalgesia in a human pain model. ​Koppert
W​1, ​Ihmsen H​, ​Körber N​, ​Wehrfritz A​, ​Sittl R​, ​Schmelz M​, ​Schüttler J​.