Rapid Buprenorphine Initiations for Cardiac Emergencies in Patients on High-dose Methadone: A Case Report.
Eloise Fourie, Megan T Mitchell, Paul Anaya et al.
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Case in brief
Two patients with opioid use disorder receiving high-dose methadone developed life-threatening arrhythmias requiring immediate methadone cessation and rapid transition to buprenorphine. During transition, one patient developed precipitated withdrawal despite a short-acting full-agonist opioid bridge, but was ultimately stabilized with higher buprenorphine doses. The other transitioned without precipitated withdrawal and did not need a short-acting opioid. The report describes buprenorphine transition as an option when QTc prolongation makes methadone reinitiation or therapeutic dosing unfeasible, while emphasizing that responses to urgent transitions vary.
What made this case unusual
The urgent transitions followed life-threatening arrhythmias in patients taking high-dose methadone, and the two patients had contrasting outcomes: precipitated withdrawal despite an opioid bridge in one, and no withdrawal without a bridge in the other.
Diagnostic / clinical pearl
Rapid transition from high-dose methadone to buprenorphine may be needed when arrhythmia and QTc prolongation preclude methadone, but precipitated withdrawal can occur even with a short-acting opioid bridge; plan for this possibility.
Why it matters
The cases underscore the need to discuss transition risks and benefits with patients and to establish an action plan for precipitated withdrawal before an urgent initiation.