Challenges in Transitioning from Methadone to Buprenorphine-Naloxone for Chronic Pain Management: Two Cases.

Background: Methadone is frequently used for chronic pain management due to its long half-life and NMDA receptor activity, making it an effective option for opioid-tolerant patients. Buprenorphine-naloxone is increasingly explored as an alternative for chronic pain and opioid use disorder, offering partial opioid agonism with a ceiling effect on respiratory depression. The transition from methadone to buprenorphine-naloxone remains clinically challenging, requiring careful management to prevent withdrawal and ensure adequate pain control.

Case descriptions: Two patients with chronic pain were transitioned from methadone to buprenorphine-naloxone. The first patient, a mid-40s female, was abruptly switched from methadone 10 mg twice daily dosing to buprenorphine-naloxone 4 mg-1 mg twice daily dosing without a taper, resulting in severe withdrawal requiring hospitalization. The second patient, a late-50s male, underwent a two-month methadone taper before initiating buprenorphine-naloxone 4 mg-1 mg twice daily dosing, but reported persistent uncontrolled pain despite dose escalation to 4 mg-1 mg three times a day. Both patients reported significant dissatisfaction with buprenorphine-naloxone therapy, citing inadequate pain relief. Both patients eventually left the practice and were lost to follow up.

Conclusion: These cases underscore the challenges of transitioning chronic pain patients from methadone to buprenorphine-naloxone formulations. Transitioning patients between these medications may lead to issues regarding withdrawal symptoms, inadequate pain control, and patient attrition.