Successful conversion from butorphanol nasal spray to buprenorphine/naloxone using a low-dose regimen to assist with opioid tapering in the setting of chronic pain and migraine management in an older adult patient: A case report

Figures & data

Table 1. Initial assessment scores.

Scoring tool	Score
Brief Pain Inventory–Severity	3.5/10
Central Sensitization Inventory	33/100
Douleur Neuropathique 4 (clinical exam not performed)	3/10
Pain Catastrophizing Scale	15/52
Prescription Opioid Misuse Index	3/6

Table 2. Buprenorphine/naloxone regimen (Using micro-dosing for initiation).

Day(s)	Buprenorphine/naloxone SL dose (buprenorphine 2 mg/naloxone 0.5 mg tabs)	Butorphanol 10 mg/mL nasal spray
1	0.5 mg/0.125 mg once daily	Maintained dose at time of initial assessment (approximately five 1 mg sprays per day)
2	0.5 mg/0.125 mg twice daily
3	1 mg/0.25 mg twice daily
4	2 mg/0.5 mg twice daily
5	2 mg/0.5 mg twice daily	Discontinued
6–25	2 mg/0.5 mg twice daily

Table 3. Summary of buprenorphine/naloxone tapering and corresponding clinical status.

Buprenorphine/naloxone sublingual dose	Days at dose	Clinical status	Number of sumatriptan doses
2 mg/0.5 mg twice daily	19	Rash/itch on patient’s back, feet, and scalp. Managed with two doses of diphenhydramine 25 mg. Rash was noticed after 7 days at target dose.	0
2 mg/0.5 mg AM + 1 mg/0.25 mg PM daily	14	Rash improved 15 days after dose reduction. No withdrawal symptoms identified.	1
1 mg/0.25 mg twice daily	14	Rash/itch almost completely gone. Not a concern for the patient. No withdrawal symptoms identified.	2
1 mg/0.25 mg daily	20	No withdrawal symptoms identified. Moderate constipation managed with polyethylene glycol 3350 daily. Started acetaminophen 500 mg PRN for mild headache.	2
0.5 mg/0.125 mg daily	7	Dramatic increase in migraine frequency. Potential withdrawal symptoms identified (i.e., generally feeling unwell).	6
1 mg/0.25 mg daily	15	Mild headache that did not impact patient’s ability to function. No withdrawal symptoms identified. Clonidine prescription returned to pharmacy for disposal.	1