High dose methadone to

buprenorphine/naloxone transfer
Dr S Conroy and D Hill, NHS Lanarkshire

Background

Methods
Development of protocol for use in outpatient
clinical setting for transfer from methadone to
Suboxone (buprenorphine/naloxone). Approval
and ratification of protocol by Addictions Clinical
Governance Group.

There are 2 commonly used and prescribed medications

for the treatment of opiate addiction, methadone
and buprenorphine. Scotlands Drug Policy Road to
Recovery (2008) and the National Forum on Drug
Related Death reports (2010 and 2011) call for increased
choice and increased availability of alternatives to
methadone prescribing by addictions services.

Patient Criteria for transfer

l

Stable on methadone
l No known allergies or previous adverse reactions
l Wanting to transfer with clear reason including
progression on personal recovery journey.
l In withdrawal from all opiates before
commencing transfer (Confirmed by Short
Opiate Withdrawal Scale (SOWS) assesment)

Buprenorphine is now more commonly being prescribed

as an alternative to methadone. Buprenorphine is
available in 2 forms within opiate substitute prescribing,
buprenorphine alone or in combination with naloxone.
In NHS Lanarkshire, these medications are prescribed
by branded product rather than generic, i.e. Subutex or
Suboxone.

Process outlined in protocol, patient must have

taken last methadone in excess of 36 hours
before commencing transfer. The buprenorphine
is administered according to a dosing protocol.
SOWS assessment and other measurements (Blood
Pressure and pulse) are taken at each incremental
dosing time prior to administration. The total
buprenorphine dose is quickly titrated to an
adequate level, 24mg routinely unless otherwise
requested by the patient.

Due to the inclusion of naloxone and the increased safety

profile of Suboxone, this is the preferred buprenorphine
formulation in NHS Lanarkshire.
As with most treatments, one medicine will not be the
best suited for all patients and many patients may do
better on buprenorphine in terms of recovery and / or
abstinence from illicit opiates. (Tanner et al, 2011)
Due to buprenorphines high affinity for the brains opiate
receptors, this medication readily displaces in-situ opiates
causing precipitated withdrawal if induction is not timed
correctly. Current recommendations for the transfer of
methadone to buprenorphine are that methadone is
lowered to a daily dose of 30mg before transfer.

Protocol for

Transfer from

Methadone to

Suboxone at

daily do

ses of Metha
than 30mg
The transfers
done greater
should only be
carried out by
Lanarkshire to
Dr Conroy, but
ensure correc
the process and
t procedure is
followed.
protocol is to
be circulated
High dose tran
to staff with in
sfer is the term
NHS
with Suboxone
used to describ
e any transfe
(at an approp
r of a patients
riate level the
medication from
patient is titra
ted to)
The patient req
more than 30m
uires having the
l methadone
to treatment
lab to ensure
recent LFT has ir liver function checked bef
ore the proces
been conduc
ted. A copy of
s
the LFT results can occur and a sample sho
Worker fully disc
should be put
uld be taken
usses transfe
and
in the patients
r with patient,
for the transfe
sent to the
notes.
If agreeing to
r by Dr S Con
roy.
the transfer, the
worker contac
ts Christine Han
The patient will
naway to arra
be
nge the date
the patients me urine screened at the app
ointment with
dical notes prio
the worker prio
r to the transfe
r to transfer and
r.
The patients
the worker sho
last
uld ensure Dr
Conroy has
last dose of me dose of methadone should
be more than
thadone should
36 hours before
patient attends
be consumed
Dr Conroy in
transfer. i.e. if
on the Saturd
a
opiates before
ay to reduce
transfer is arra
withdrawal sta
the possibility
the appointme
nge
te on the day
d
for
the Monday,
of precipitate
of transfer. The
nt for transfer,
the
d withdrawal,
and that they
and ensure the
will need to atte patient should be reminded
The patient sho
they are not to
nd in a state
uld attend Dr
of withdrawal
use any other
Conroy at 9.3
.
0am on the day
of
On attending
transfer.
the
withdrawal and patient will be examined and
the information
assessed usin
they have give
g
n is correct. I.e. the SOWS withdrawal sca
le and will sign
The transfer pro
consent to the
to agree the sco
cess with the
transfer.
n begin.
re of
The initial dos
e of Suboxone
will be 2mg. The
approximate
time scale for
patient will be
the transfer is
titra
ted
to an appropriat
below.
e level of sub
oxone in the
clinic. The
Suboxone initi
9.30
ation chart
Initial dose
2mg Suboxone
10.30
Requires sup
ervision and obs
2mg Suboxone
for first 30 min
ervation
utes then che
ck
11.30
Continue che
cks 15 min inte every 15 minutes
2 x 2mg Suboxo
rvals
ne
12.30
Continue che
cks at 20-30
min intervals
8mg Suboxone
Continue che
cks at 20-30
13.30
If
pat
ien
t doing well, can min intervals
if required
leave for lunch
8mg Suboxone
Continue to che
ck at 30 min inte
The observatio
rvals
n checks sho
uld be used to
symptoms.
identify the pat
ients progress
and lack of pre
cipitated with
Patient can be
drawal or with
discharged onc
drawal
effects.
e the appropriat
e dose of Sub
oxone is reache
d and there are
Patient should
no
further withdra
be provided with
wal
sym
ptoms or side
addictions tea
a prescription
m.
at the approp
riate Suboxone
dose until the
Patient notes
date of their nex
should be retu
t appointment
rned to the add
with the
iction team bef
ore the next app
ointment is due
Protocol for Tran
with the worker
sfer from Met
Authors: Dr S
hadone to Sub
.
Con
oxo

roy and D Hill

ne at daily dos
Written: Aug
es of Methad
ust 2012
one greater than
Approved by
30mg
Clin
Review: August ical Governance: August
2012
2013

Presenters Contact Details

Duncan Hill

Specialist Pharmacist in Substance Misuse

NHS Lanarkshire, Airbles Road Centre,
49 -59 Airbles Road
Motherwell, ML1 2TP
Mob: 0792 0711131
e-mail:Duncan.hill@lanarkshire.scot.nhs.uk

Many patients on methadone are stabilised on doses far

in excess of 30ml, thus transferring to suboxone involves
a gradual reduction, which may be difficult or impossible
for some, before transfer.

Dr. Steve Conroy

Lead Medical Prescriber Alcohol and Drug Service,

NHS Lanarkshire,Coathill House,
Old Monkland Road,
Coatbridge, ML5 5EA
Mob: 0777 5800213
e-mail: Stephen.Conroy2@lanarkshire.scot.nhs.uk

This paper sets out to demonstrate that transfers can be

done from doses of methadone much greater than 30ml
without any requirement for reduction in advance.

Results
Short Opiate Withdrawal Scale vs Dose administered

35

The dosing protocol used for the transfer of patients

from more than 30mg daily of methadone to
buprenorphine / naloxone is
safe,
effective
allows rapid stabilisation
for patients on their new opiate substitute, without
the need to undergo protracted dose reduction, and
the risks associated with this.

30

SOWS Score

25
20
15
10
5
0

Conclusion

Initial

2mg

All patients were transferred from a range of

methadone doses (35 120mg).
The Opiate withdrawal experienced does
not correlate to the dose of methadone. The
withdrawal scale is very subjective to the patient
individually and their tolerance of symptoms.
All transfers have been concluded successfully with
no adverse events reported by patients.
As can be seen from the graph of SOWS
(Short Opiate Withdrawal Scale) against dose,
buprenorphine/naloxone significantly and
rapidly alleviates the withdrawal experiences
of the patients, and all at the end have fewer
symptoms than at commencement of the transfer;
demonstrating the patient feels much better before
the final tablet and end of the transfer process.

4mg
Dose

8mg

16mg

Patients reported having a number of positive

results and experiences since commencing
buprenorphine/naloxone, including continuation
of recovery journey, return to employment /
education and abstinence from illicit drugs.
Transfer protocol is:

Safe
Effective
Rapid
Appropriate and applicable for transfers from
all doses of methadone

There is no requirement to alter the dispensing

supply/ supervision arrangements with the
transfer.

Further work and analysis of the transfer process is

continuing and will be submitted for publication in
due course.

References
Scottish Government. (2008). The Road to Recovery: A New
Approach to Tackling Scotlands Drug Problem. Edinburgh:
Scottish Government.
National Forum on Drug Related Deaths in Scotland Annual
Report 2009-10 Online document (http://www.scotland.gov.uk/
Resource/Doc/320254/0102413.pdf) Edinburgh
National Forum on Drug Related Deaths in Scotland Annual Report
2010/11
National Forum on Drug Related Deaths in Scotland Annual
Report 2010-11 Online document (http://www.scotland.gov.uk/
Publications/2011/11/6842/4) Edinburgh
Tanner, G.R., Bordon N., Conroy, S. and Best, D. 2011. Comparing
methadone and Suboxone in applied treatment settings: the
experiences of maintenance patients in Lanarkshire. 16(3): pp.
171-178.
CTP.HDMBNT.93045.P