one month prior . The patient ’ s urine drug screen was positive only for methadone and no other relevant laboratory abnormalities .
The patient had a past psychiatric history of unspecified psychotic disorder ( substance induced or primary thought disorder ) and multiple SUDs such as opioid , stimulant , tobacco , and cannabis . There was no family history of depression , anxiety , bipolar disorder , or schizophrenia . The patient did have a family history of alcohol use disorder , and his father had attempted suicide . The patient had four prior admissions for suicidal ideation , psychosis , paranoia , and polysubstance intoxication .
Upon admission , he reported having myalgia , tactile hallucinations , weakness , and malaise . Paranoia and persecutory delusions were noted during the interview . He received a dose of 10 mg oral olanzapine at that time for his paranoia and delusions . On admission day two , his 140 mg / day methadone dose was verified with the local OTP . He was restarted on methadone and later indicated improved myalgia , weakness , and malaise . He no longer reported symptoms consistent with paranoia , delusions , or hallucinations , although he did state that he had a degree of disorganized thinking for which he was initiated on olanzapine ( 10 mg nightly ). Over the next several days , the patient ’ s thought content continued to normalize . On admission day five , the patient stated he would like to convert from methadone to SL BUP-NX maintenance treatment . He stated he was “ tired of jumping through all of the hoops of the methadone clinic ” and felt SL BUP-NX treatment would be easier to sustain . On admission day six , he was offered a micro-dosing regimen to rapidly convert from high dose methadone to SL BUP-NX maintenance . The patient consented to the regimen ( Table 2 ), and it was implemented that day .
On regimen day three , the patient experienced some mild nausea and headache , which were successfully treated with oral ondansetron and ibuprofen , respectively . On regimen day five , the patient expressed some mild nausea , which resolved with oral ondansetron . He was discharged on
TABLE 1 : Micro-dosing Regimen for patient in Case Report 1 Day SL BUP-NX Dose Directions Total Daily Dose-BUP Methadone Dosing 1 0.5-0.125 mg once daily 0.5 mg 195mg once daily 2 0.5-0.125 mg twice daily 1.0 mg 195mg once daily 3 1.0-0.25 mg twice daily 2.0 mg 195mg once daily 4 2.0-0.5 mg twice daily 4.0 mg 195mg once daily 5 4.0-1.0 mg twice daily 8.0 mg 195mg once daily 6 4.0-1.0 mg three times daily 12.0 mg 195mg once daily 7 8.0-2.0 mg twice daily 16.0 mg 195mg once daily 8 8.0-2.0 mg twice daily 16.0 mg 0 mg ( Discontinued ) Abbreviations : SL BUP-NX - sublingual buprenorphine / naloxone , BUP-buprenorphine
TABLE 2 : Micro-dosing Regimen for patient in Case Report 2 Day SL BUP-NX Dose Directions Total Daily Dose-BUP Methadone Dosing 1 0.5-0.125 mg twice daily 1.0 mg 140 mg once daily 2 1.0-0.25 mg twice daily 2.0 mg 140 mg once daily 3 2.0-0.5 mg twice daily 4.0 mg 140 mg once daily 4 4.0-1.0 mg twice daily 8.0 mg 140 mg once daily 5 8.0-2.0 mg twice daily 16.0 mg 140 mg once daily 6 8.0-2.0 mg twice daily 16.0 mg 0 mg ( Discontinued ) Abbreviations : SL BUP-NX - sublingual buprenorphine / naloxone , BUP-buprenorphine
regimen day six having successfully transitioned . At that time , he stated he felt good and exhibited no thought process abnormalities . He was discharged on the following medications : SL BUP-NX ( 8-2 mg twice daily ), mirtazapine ( 15 mg nightly ), and olanzapine ( 10 mg nightly ). He was discharged with an outpatient appointment to be seen in our clinic four days later . The patient missed his clinic appointment despite case management efforts .
DISCUSSION
Methadone was introduced to the medical community in 1946 as a potent analgesic . 1 In 1965 , it was reported that a group of 22 patients addicted to heroin had been stabilized using oral methadone . 2 The authors concluded that methadone decreased narcotic hunger and blocked the euphoric effect of an average illegal dose of heroin . 2 The results were pivotal in the early care of a previously untreatable illness . 3
The maintenance dose of methadone is generally between 80-120 mg / day . 4 However , there is significant variability in the daily doses required to reduce opioid craving and suppress withdrawal . 4 There is a dose-dependent increase in the risk of prolonging the QTc-interval , thereby increasing the risk of torsades de pointes , after methadone administration . 5 In order to receive methadone treatment for opioid addiction maintenance , it must be prescribed and dispensed by a certified OTP . 4 This requirement often creates significant logistical problems for patients being treated for opioid use disorder ( OUD ). 6
Buprenorphine is the first partial opioid medication to treat OUD that can be prescribed or dispensed in physician offices . 7 This situation significantly increases access to the drug . 7 Buprenorphine is a partial mu-opioid receptor agonist and has a more favorable adverse effect profile compared with a full mu-opioid receptor agonist such as methadone . 7 There
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