More buprenorphine stories

[ateria radicularis magna]

There seems to be a prevalence of people using or wanting to use buprenorphine more for chronic pain.

Reasons PRO (some debatable):
Less addictive
Less prone to abuse
Less euphoric
Less tolerance
Reverse tolerance
Less respiratory depression (but
same if on other respiratory depressants)
Schedule 3
Doesn’t show up in popular music as far as I know.
No buprenorphine pill mills (suboxone/ chain addiction centers are another story).


Cons:
Transition to buprenorphine from a schedule 2 drug of choice often results in frustration because patient is going through either normal or precipitated withdrawal during transition and thinks the buprenorphine isn’t working, or is harming, as a result.***
Sometimes it seems like the insurance wants the patient “to have failed” meds like fentanyl patch before approving!!
Cost issues.****
The skin rash
The dry gums thing
The sweaty person
The serotonin issue
The googling patient who tells “you that’s for addiction, man, you think I’m an addict? I have a high pain threshold! I’m going to write you a terrible online review and sue you for 5 million, you rat F***.”


Random thoughts
1. The buprenorphine pills are much cheaper, but rarely discussed, maybe due to lack of industry ties (in contrast to butrans and Belbuca, who marketed a fair amount, I think). Why don’t we all just use the pills instead of butrans or belb? Hard to cut them up? Weird doses? More prone to abuse? What am I missing? Fill me in.

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[deleted131481]

I agree with most of your list. Most of those cons are basically no opioid/ so excuses they don't want it.

Cost seems to be an issue - with my patient population in anything more than a few dollars. However I have Medicaid patients on Belbuca.

If I'm not mistaken the lowest dosage tablet form is 2 mg. I believe that it can and has been abused and that was the purpose of Suboxone to add naloxone to it.

Would love to see a generic lower dose form.

 

[RoloTomassi]

Why don’t we all just use the pills instead of butrans or belb?

I think the sublingual tabs are only indicated for opioid addiction, not pain, and you have to have a special designation or something like that. Maybe someone can confirm. Never made sense to me.

 

[drusso]

I think the sublingual tabs are only indicated for opioid addiction, not pain, and you have to have a special designation or something like that. Maybe someone can confirm. Never made sense to me.

You can prescribe off-label for anything you want. The molecule is stupid. It doesn't know its indication.

 

[RoloTomassi]

You can prescribe off-label for anything you want. The molecule is stupid. It doesn't know its indication.

But don't you have to have a special DEA # or addictionology certificate?

 

[lobelsteve]

But don't you have to have a special DEA # or addictionology certificate?

No. If writing for addiction there is a DEA X waiver required and a limit on how many people you can rx for.

 

[bedrock]

There seems to be a prevalence of people using or wanting to use buprenorphine more for chronic pain.

Reasons PRO (some debatable):
Less addictive
Less prone to abuse
Less euphoric
Less tolerance
Reverse tolerance
Less respiratory depression (but
same if on other respiratory depressants)
Schedule 3
Doesn’t show up in popular music as far as I know.
No buprenorphine pill mills (suboxone/ chain addiction centers are another story).


Cons:
Transition to buprenorphine from a schedule 2 drug of choice often results in frustration because patient is going through either normal or precipitated withdrawal during transition and thinks the buprenorphine isn’t working, or is harming, as a result.***
Sometimes it seems like the insurance wants the patient “to have failed” meds like fentanyl patch before approving!!
Cost issues.****
The skin rash
The dry gums thing
The sweaty person
The serotonin issue
The googling patient who tells “you that’s for addiction, man, you think I’m an addict? I have a high pain threshold! I’m going to write you a terrible online review and sue you for 5 million, you rat F***.”


Random thoughts
1. The buprenorphine pills are much cheaper, but rarely discussed, maybe due to lack of industry ties (in contrast to butrans and Belbuca, who marketed a fair amount, I think). Why don’t we all just use the pills instead of butrans or belb? Hard to cut them up? Weird doses? More prone to abuse? What am I missing? Fill me in.

I agree with most of your list. Most of those cons are basically no opioid/ so excuses they don't want it.

Cost seems to be an issue - with my patient population in anything more than a few dollars. However I have Medicaid patients on Belbuca.

If I'm not mistaken the lowest dosage tablet form is 2 mg. I believe that it can and has been abused and that was the purpose of Suboxone to add naloxone to it.

Would love to see a generic lower dose form.

Regarding cost/coverage, now that butrans has gone generic, and belbuca caused even the generic butrans price to drop to reasonable levels with coupons etc, I just mandate to any patient requiring ME >30, must convert to butrans or find another clinician.

I don't play any games with insurance coverage/having to try fentanyl patches first or whatever BS. I tell the patients that they have to switch and pay for butrans or they find another physician, period. I have spoken with several local pharmacists and found discount codes and other programs for butrans. (This varies by area, so consult your local pharmacist), but the monthly out of pocket cost to these patient is $50-60 for butrans (cash price regardless of insurance) and so I tell them I don't care that they can get a month of Norco for $10 instead of $50 for butrans, because if they want the norco, then it will be on the license of someone else. It is rdiculous to expect that we should risk our licenses because the patient can't pay $50 a month. Everyone can find $50/month for something important. There are help wanted signs on every other street in the USA right now, so I don't accept cost as an excuse when the price is that low.

There are genuine reliable patients who have real anatomic issues and get by on norco QD or BID, which I allow. Sometimes I write Percocet QD-BID for patients with more severe pathology. But doses of standard opioids more than BID I don’t allow,, because once opioids are hitting the body more than twice a day, you are just creating tolerance and the patient must switch to butrans if they need more than BID dosing.

I start with butrans because the 5 or 7.5mcg/hr dose causes less side effects than cutting up a bup pill, and because Butrans provides more reliable dosing than cutting a 2mg bup pill into quarters.

Once you've established via butrans that their body can tolerate the bup molecule( so no excuses from the patient), then I will consider higher bup doses with either butrans or belbuca/bup bills.
Similarly, if the patient has insurmountable issues with a butrans rash or it wearing off at day 6, (instead of 7), or they require higher dosing than butrans 20mcg, then I give patients the option of belbuca or cutting up bup pills and that decision is often driven by cost/convenience.

And for patients with medical contraindications to standard opioids such as respiratory problems etc, they only get butrans as an initial option.
As I said, now that butrans is $50-60 with a coupon, I don't allow cost to be an excuse ever again.

 

[deleted472101]

The main difference between buprenorphine / naloxone buccal film and sublingual tablets is a two-fold greater bioavailability due to greater absorption

Randomised Comparison of a Novel Buprenorphine Oral Lyophilisate versus Existing Buprenorphine Sublingual Tablets in Opioid-Dependent Patients: A First-in-Patient Phase II Randomised Open Label Safety Study - PubMed

Orally disintegrating buprenorphine oral lyophilisate wafer disintegrated rapidly. No increased respiratory depression was found and clinically no difference between medications was observed. PK found substantially increased bioavailability of buprenorphine (but not of nor-buprenorphine) with...

pubmed.ncbi.nlm.nih.gov

 

[Orin]

The use of Suboxone or the other addiction things is limited by policies at many pharmacies requiring a waiver for it, even if you're using it off-label.

The bioavailability of the sublingual tablets when taken orally is about 10-20% so I start them on the 2 mg cut in half and taken PO if they can't afford Belbuca/Butrans. The kinetics of that though are not as reliable so it may need TID dosing rather than QD/BID. With the large therapeutic window when taken without other synergizing respiratory depressants, I'm not as worried about overdosing with that variability but it's a lot of talking/documenting, and then a constant fight with the pharmacy policies or EMR systems.

 

[NJPAIN]

The use of Suboxone or the other addiction things is limited by policies at many pharmacies requiring a waiver for it, even if you're using it off-label.

The bioavailability of the sublingual tablets when taken orally is about 10-20% so I start them on the 2 mg cut in half and taken PO if they can't afford Belbuca/Butrans. The kinetics of that though are not as reliable so it may need TID dosing rather than QD/BID. With the large therapeutic window when taken without other synergizing respiratory depressants, I'm not as worried about overdosing with that variability but it's a lot of talking/documenting, and then a constant fight with the pharmacy policies or EMR systems.

Sounds like a lot of work for questionable benefit to all involved. But, I’m interested to hear of a few particular scenarios in which you have used it and feel that it was beneficial.

 

[bedrock]

Sounds like a lot of work for questionable benefit to all involved. But, I’m interested to hear of a few particular scenarios in which you have used it and feel that it was beneficial.

True that this can happen with bup pills and some pharmacies. That is why I use the butrans for all approach, because it is reasonably affordable and you don't get pharmacy pushback.

If you have a patient population that would regularly need higher doses of bup, so in pill form, then just get the x-waiver, the one day waiver course counts as CME, and afterwards the pharmacies generally leave you alone.

 

[deleted875186]

I’ve had many more insurances cover Butrans this year compared to last, actually having very few issues now.

my states Medicaid covers Butrans, the brand name is actually cheaper than the generic bup patch apparently because it is preferred.

I have yet to have a reasonable patient with real pathology have significant issues requiring stopping or total lack of any benefit from bup. I get occasional sweating, skin irritation, or mouth irritation.

 

[geauxg8rs]

I’ve had many more insurances cover Butrans this year compared to last, actually having very few issues now.

my states Medicaid covers Butrans, the brand name is actually cheaper than the generic bup patch apparently because it is preferred.

I have yet to have a reasonable patient with real pathology have significant issues requiring stopping or total lack of any benefit from bup. I get occasional sweating, skin irritation, or mouth irritation.

I have had either coverage for the butrans or generic, or belbuca. Last one to try and deny I asked for a schedule III net zero MED formulary alternative and was approved

 

[secants]

Slightly off topic but I've inherited a few opioid legacy patients, mostly failed backs on >90 MME. Anyone try and convert these guys to methadone instead given that bup sometimes just doesn't cut it.

 

[lobelsteve]

Slightly off topic but I've inherited a few opioid legacy patients, mostly failed backs on >90 MME. Anyone try and convert these guys to methadone instead given that bup sometimes just doesn't cut it.

Why would you risk the QT prolongation and unpredictable half life and social stigma and there is still a MEQ to methadone.
Nothing but bad idea.

 

[ateria radicularis magna]

I have had either coverage for the butrans or generic, or belbuca. Last one to try and deny I asked for a schedule III net zero MED formulary alternative and was approved

Can you clarify net zero MED formulary? Who did tou address this concern to after the denial?

 

[deleted875186]

Slightly off topic but I've inherited a few opioid legacy patients, mostly failed backs on >90 MME. Anyone try and convert these guys to methadone instead given that bup sometimes just doesn't cut it.

I find most failed back surgery patients terrible candidates for opioids, especially methadone, convert them and they’ll be exactly the same type of pain but now with a more risky opioid.

 

[NJPAIN]

True that this can happen with bup pills and some pharmacies. That is why I use the butrans for all approach, because it is reasonably affordable and you don't get pharmacy pushback.

If you have a patient population that would regularly need higher doses of bup, so in pill form, then just get the x-waiver, the one day waiver course counts as CME, and afterwards the pharmacies generally leave you alone.

I’ve had a x -waiver for close to 15 years if not more. I’m not really enthusiastic about using a drug (Suboxone or Subutex) intended for OUD off label for pain. Sure you can label anyone with OUD. Sure we use other drugs off label and don’t worry about that too much. However, in my mind this is different. First, I question the benefit of COT to the patient. Second I envision that the patient will not embrace transitioning from their candy to Subutex without push back. Third I would not be surprised if they do something to provide “proof” that Subutex is the wrong drug for them. Fourth I can imagine in front of the Board of Medicine or in a court of law the fact that this is a drug not FDA approved for pain is going to be made into a major issue for the purpose of making it look like the physician has done something wrong.

 

[SeniorWrangler]

Slightly off topic but I've inherited a few opioid legacy patients, mostly failed backs on >90 MME. Anyone try and convert these guys to methadone instead given that bup sometimes just doesn't cut it.

Clinically, very low dose methadone might make sense (5mg/day or so), but there's a big stigma around methadone for chronic pain and I never start it for non-cancer pain. The main issue is the long half-life -- if the patient escalates the dosage, they could easily overdose.

 

[Ferrismonk]

Slightly off topic but I've inherited a few opioid legacy patients, mostly failed backs on >90 MME. Anyone try and convert these guys to methadone instead given that bup sometimes just doesn't cut it.

I've done a ton of Methadone conversions in fellowship and just a couple outside that. In general Methadone is a very effective drug for pain and I do find it tends to work well for people tolerant to other opioids, especially if their pain is primarily neuropathic. It's also dirt cheap which is nice.

That being said I would NEVER convert high-dose people to Methadone again. It has been shown to be much more dangerous from an overdose perspective than other opioids. Biphasic metabolism, prolonged QTc with so many other drugs out there that prolong the QTc, etc. Additionally the MMED calculations get wonky at high doses.

Buprenorphine is SO much safer. Methadone maintenance therapy can make sense when given daily, in liquid form, by a OUD clinic.

 

[Ducttape]

there is very little reason to be starting methadone for chronic nonpalliative pain on any one at this point in time, given all of the other options available (including cessation if they are allergic to all other forms of opioids and all other medications used for pain available).

the long half life is a huge issue as mentioned, but also the various drug interactions, and not just with the obvious ones with benzos.



one of the pain docs in the surrounding community was penalized for prescribing suboxone for chronic pain off label, as part of the multiple complaints the DEA and DOH raised against him. I would suggest that anyone who is going to prescribe it off label consider getting the X waiver.