Buprenorphine to Methadone Conversion For Acute Pain Management in a Patient with Substance Use Disorder

Rakhi Dayal MD, George Mina BS

UCI School of Medicine 

 

Introduction

• Acute pain management is challenging, especially with rising trends in substance use disorders.

• Lack of addiction medicine specialists often leaves pain management physicians responsible for managing untreated substance use disorders.

• A recent NIH study found that 74% of physicians reported insufficient skill, and 72% reported inadequate knowledge in managing addiction.

• This case focuses on the pharmacological conversion to Methadone for a patient with recent high-dose Fentanyl and Suboxone use, and examines the correlation between Fentanyl dosage and Methadone recommendations.

  
  

  Case Description

  • Patient: 28-year-old male with daily 1g Fentanyl use, recent Suboxone use (2 mg QID), and legal constraints on his medical record.

  • Presented with uncontrolled pain after facial wound exploration surgery.

  • Initial pain management:

  • PCA Hydromorphone (137 mg over 7 days)

  • Gabapentin, Cyclobenzaprine, Ketorolac, and Ketamine infusion.

  • Patient refused to restart Suboxone, agreed to Methadone initiation.

    
    

    Results

    • Despite multimodal analgesia, pain persisted (8-10/10).

    • Ketamine provided the most relief.

    • Methadone was started at 5 mg-5 mg-10 mg, titrated up to 10 mg TID, then to 15 mg TID, higher than the standard dose (2.5 mg).

    • Pain scores reduced significantly from 10/10 to 1-2/10.

    • Discharged on Methadone, Morphine liquid solution, Tylenol, Gabapentin, and Cyclobenzaprine.

       

      Discussion

      • Methadone’s analgesic duration (6-8 hours) contrasts with its anti-craving effects (>24 hours).

      • Higher initial Methadone doses (10 mg TID) may be effective for managing acute pain in patients with high-dose Fentanyl and Suboxone use.

      • Further research is needed to develop guidelines for Methadone dosing in this specific patient population.

        
        

        Conclusion

        
        

        •  Complex pain management in patients with substance use disorders requires specialized knowledge and skills

        • Higher Methadone doses may provide effective acute pain relief in opioid-tolerant patients.

        • Multimodal pain management and individualized dosing are key.

        • More research is required to establish best practices for Methadone use in complex substance use disorder cases.