From the Psychiatry Residency Spokane, Providence Sacred Heart Medical Center, Spokane, WA, USA (HB, RHC, JFW); University of Washington School of Medicine, Seattle, WA, USA (KLF); Creighton University Arizona Health Education Alliance, Phoenix, AZ, USA (KLF); Providence Medical Research Center, Providence Health Care, Spokane, WA, USA (EJC).
J Addict Med. 2022;16(4):488-491. doi: 10.1097/ADM.0000000000000935. Epub 2021 Dec 3.
Patients with opioid use disorder (OUD) who are managed on methadone often require transition to buprenorphine therapy. Current recommendations require months to gradually taper off of methadone; however, in some cases, the need to transition is urgent. Only a few rapid methadone-to-buprenorphine transitions have been reported and there are no established protocols to guide clinicians in these cases.
A 43-year-old man on 95 mg methadone for opioid use disorder experienced cardiac arrest attributable to ventricular fibrillation caused by QTc interval prolongation from methadone. In the hospital, a gradual taper of methadone was initiated but proved intolerable; the patient requested to restart his home dose of methadone and leave against medical advice. A rapid transition was initiated instead. Naltrexone (25 mg) was used to precipitate acute withdrawal followed 1 hour later by a "rescue" with buprenorphine/naloxone (16 mg/4 mg). The Clinical Opiate Withdrawal Score (COWS) peaked at 21 post-naltrexone and fell quickly to 15 within a half-hour of buprenorphine/naloxone administration. The patient was maintained on a total daily dose of 16 mg/4 mg buprenorphine/naloxone through the time of discharge.
A patient requiring an urgent taper off of methadone due to adverse cardiac effects successfully transitioned to buprenorphine/naloxone within 2 hours by using naltrexone to precipitate withdrawal followed by a "rescue" with buprenorphine/naloxone. A relatively high dose of 16 mg/4 mg buprenorphine/naloxone successfully arrested withdrawal symptoms. With further refinement, this protocol may be an important technique for urgent methadone-to-buprenorphine transitions in the inpatient setting.
接受美沙酮治疗的阿片类药物使用障碍（OUD）患者通常需要过渡到丁丙诺啡治疗。目前的建议需要数月时间逐渐减少美沙酮；然而，在某些情况下，过渡的需求是紧急的。只有少数快速美沙酮到丁丙诺啡的转换被报道，并且没有既定的方案来指导这些情况下的临床医生。
一名 43 岁男子因美沙酮引起的 OUD 接受 95 毫克美沙酮治疗，因美沙酮引起的 QTc 间期延长导致心室颤动而发生心脏骤停。在医院，开始逐渐减少美沙酮，但被证明无法耐受；患者要求重新开始他的家庭剂量美沙酮并违反医嘱离开。取而代之的是开始快速转换。纳曲酮（25 毫克）用于引发急性戒断，1 小时后用丁丙诺啡/纳洛酮（16 毫克/4 毫克）进行“抢救”。纳曲酮后 1 小时，纳洛酮的 COWS 峰值达到 21 分，并迅速降至丁丙诺啡/纳洛酮给药后半小时内的 15 分。患者在出院时维持丁丙诺啡/纳洛酮的总日剂量为 16 毫克/4 毫克。
一名因心脏不良事件需要紧急减少美沙酮的患者，通过使用纳曲酮引发戒断，随后用丁丙诺啡/纳洛酮进行“抢救”，在 2 小时内成功过渡到丁丙诺啡/纳洛酮。丁丙诺啡/纳洛酮的相对高剂量为 16 毫克/4 毫克，成功阻止了戒断症状。经过进一步改进，该方案可能是住院患者紧急美沙酮到丁丙诺啡转换的重要技术。
