(125) Yikes! Methadone To Buprenorphine Transition During Pregnancy, In Jail, Via Telephone

Background & Introduction: Buprenorphine and methadone are both highly effective, FDA-approved medications to treat opioid use disorder during pregnancy. Buprenorphine can be prescribed by any prescriber with a DEA license, while methadone is only available at certified opioid treatment programs, limiting its access, particularly in rural areas. Transitioning from methadone to buprenorphine can take weeks or longer, especially for patients taking high-dose methadone (>100mg) daily, and many people experience opioid withdrawal symptoms while making this switch. Most published protocols for transition from methadone to buprenorphine report high rates of opioid withdrawal [1]. Opioid withdrawal symptoms during pregnancy may increase the risk of miscarriage and thus are generally avoided. Methods for switching from methadone to sublingual (SL) buprenorphine that do not cause opioid withdrawal symptoms are needed. To our knowledge, no reports in the literature have described a protocol for transition from high-dose methadone to SL buprenorphine in less than 30 days without opioid withdrawal.

Case Description: The patient is a 25-year-old female with opioid use disorder (OUD) who was 24 weeks pregnant and had been incarcerated for 3 months in a county jail at the time of presentation. She was taking methadone 130mg daily and, prior to incarceration, had been enrolled in an opioid treatment program (OTP) near her hometown, in an adjacent state. The OTP was not willing to continue sending methadone to the jail without seeing her periodically, and the jail staff were not willing to transport her 2 hours away and across state lines to the OTP. No local OTPs were willing to enroll her. Transition from methadone to buprenorphine was requested by the jail staff so she could continue medication treatment for OUD. Due to the COVID-19 pandemic, jail procedures, and because the referral came just before the winter holidays, our assessment, treatment plan, and monitoring was provided via audio-only telehealth care. At the time of referral, the jail had 22 bottles of liquid methadone, 130mg each. The nurse in the jail was not willing to administer a partial dose of methadone, only the full bottle. We developed a low-dose titration protocol for buprenorphine to overlap with methadone 130mg daily x 22 days. At the end of 22 days, the methadone was stopped and a stable dose of buprenorphine 32mg daily was continued. The patient tolerated the transition with occasional mild nausea that was relieved with promethazine, but no other withdrawal symptoms. She noted fetal movement throughout the transition, with no vaginal bleeding, cramping, or loss of fluid. She remained on buprenorphine 32mg SL daily through her pregnancy, and at 39 6/7 weeks she delivered a healthy 4020g male infant with APGAR’s of 6 and 9 by normal spontaneous vaginal delivery. Following delivery, she was transferred to a prison out of state to serve a 12-month sentence, and she was able to continue buprenorphine throughout her sentence. She has since been released from prison, has resumed care in our medication for addiction treatment (MAT) clinic and is taking buprenorphine/naloxone 24/6mg daily with good effect. The patient consented to sharing her story after she was released from incarceration.

Conclusion & Discussion:

This poster describes a novel approach for transition from high-dose methadone to buprenorphine via a very low dose initiation, during pregnancy, in a jail, and via audio-only telehealth. The strategy was developed out of limited options related to pregnancy, incarceration, methadone regulations, and rurality. If it had been an option to adjust the dosing of methadone, the transition would likely not have occurred in this manner. However, the patient tolerated the cross-over extremely well, with very minimal adverse effects, and continued to follow in our MAT clinic. To our knowledge, there are no other known cases of transitioning from high-dose methadone to buprenorphine, using a very low dose titration, in a pregnant patient, in less than 30 days, with minimal or no withdrawal symptoms. This case highlights the need for continued methadone flexibilities, while also highlighting a potential option to transition someone from high-dose methadone to buprenorphine without opioid withdrawal symptoms.

References: 1) Lintzeris, Nicholas BMedSci, MBBS, PhD, FAChAM; Mankabady, Baher MD; Rojas-Fernandez, Carlos PharmD; Amick, Halle MSPH. Strategies for Transfer From Methadone to Buprenorphine for Treatment of Opioid Use Disorders and Associated Outcomes: A Systematic Review. Journal of Addiction Medicine 16(2):p 143-151, March/April 2022.

2) Johnson, S., & Martin, P. R. (2017). Transitioning from methadone to buprenorphine maintenance in management of opioid use disorder during pregnancy. The American Journal of Drug and Alcohol Abuse, 44(3), 310–316.

3) Coish, Rebecca MD, CCFP(AM); Hardial, Janine MD, CCFP, FCFP. Successful Buprenorphine/Naloxone Low-dose Induction in Pregnancy: A Case Report. Journal of Addiction Medicine 17(1):p 114-116, 1/2 2023.