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Comparing Sublingual Buprenorphine vs Butrans

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This question was submitted through pcssNOW.org:

I am confused about comparing suboxone with butrans patch.  My understanding is that giving someone 8 mg of suboxone is way more dose than what anyone on butrans patch will have.  I also realize that butrans patch is used in pain medicine and suboxone in addiction medicine.  1. But how much mcg of butrans is equivalent to suboxone 8 mg?  2. I realize that splitting up the suboxone dose throughout the 24 hr period helps with pain. But I think I heard that giving someone a little more suboxone (like a quarter of a 8 mg film) can help when they have pain.   Is that true? And if so what fraction of the 8 mg film will help with pain?

 

Dr. Anthony Dekker responds:

Sublingual buprenorphine is indicated for OUD withdrawal maintenance and detoxification but none for pain treatment in the US.  The EU has approved sublingual doses for pain.  Trans dermal and trans buccal forms exist for pain.  Injectable buprenorphine has been approved for pain for decades.

Butrans comes as 5, 10 and 20 mcg per hour.  This is a fraction of the sublingual dose.  Sublingual buprenorphine has about a 50% absorption in the body.  Remember that buprenorphine has an 80% first pass effect of swallowed past the distal third of the esophogus.

Many providers are using sublingual buprenorphine off label for pain.  Since the absorption is highly related to sublingual exposure (and prevention of swallowing) I do not advise unproven guesswork by cutting strips or using pill fragments for pain.

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Hello,

I found the above thread helpful for a current patient that I am confused about:

I am a newly-waivered family medicine physician with a panel of about 6 MAT patients.  I recently received a new referral for a 61yof on buprenorphine sublingual tablets (monoproduct, no naloxone) 6mg once daily.  Upon my interview with her I do not find any evidence that she meets the DSM-V criteria for OUD.  She is just taking it for chronic knee pain.  Her previous pain doctor retired and couldn't find anyone else to takeover prescribing.  While this is not something I specifically need the waiver for, it is still out of my element because I don't have any other patients on buprenorphine solely for pain.

So far I'm learning that this appears to be off-label use of buprenorphine.  The buccal and transdermal routes would be FDA approved for chronic pain but not the SL forms. 

Should I try to switch her to a Butrans patch for the sake of safety and ease of administration?

How would I go about switching to a patch?  As per the above thread, a 5mcg/hr patch is a fraction of the sublingual dose.  Is there some dosage conversion factor I should use to switch from SL to transdermal?  I'm not finding anything on UpToDate to help me on this.

 

Thanks,

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On 6/8/2020 at 2:59 PM, JMullins said:

How would I go about switching to a patch?  As per the above thread, a 5mcg/hr patch is a fraction of the sublingual dose.  Is there some dosage conversion factor I should use to switch from SL to transdermal?  I'm not finding anything on UpToDate to help me on this.

 

Dr. Anthony Dekker has provided this response:

Buprenorphine tabs (sublingual formulation) may be used off label for pain.  The sublingual formulation is much less expensive than the buccal or patch formulations.  Typically buprenorphine has been more successful in treating neuropathic type pains ie lumbago.  Many of the MSK pains from arthritis, fractures and periosteal pain has not been responsive.  The EU has an approved buprenorphine SL tab at 0.3mg.  I believe the UK also has that formulation.  I use buprenorphine for pain (well documented in the medical record). Remember that OUD hx trumps pain and if you have a patient with OUD the use of buprenorphine would be for that reason even if you are prescribing it for pain also.

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Buprenorphine is a very strong pain medicine. People with OUD tend to have much higher dosage needs than those with chronic pain without OUD.

In my opinion, Bupe is a safer opioid for the majority of chronic pain patients on opioids (but it's still an opioid so don't give it to opioid naive pain patients).

It's difficult to come up with conversions between the forms. See this table from Gudin's Pain Ther https://doi.org/10.1007/s40122-019-00143-6

A Butrans 20mcg/hour patch is 1/4 of a 2mg buprenorphine for total mg, but how much is absorbed is confusing, and there are case reports of transitioning people on staggering doses of opioids using just a 20mcg/hr patch so it's deceivingly powerful.

See Saal & Lee's case series on using Butrans to start patients on bupe from full agonists. https://doi.org/10.7812/TPP/19.124

I'd suggest only using Butrans as a bridge from full agonists to sublingual bupe (because buccal bupe FDA approved for pain is not obtainable for many patients) for those in the MED 30-120 range. though expert opinion and case series is the best evidence we have for this now

 

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