Buprenorphine for pain

[likeaboss]

What is everyone's experience with buprenorphine for pain? I've only given butrans patches from 5 to 20 mcg and find that it isn't really strong enough for many patients with chronic pain. What about belbucca, and Subutex? Is the 2mg Subutex too much?

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[TIVAndy]

i usually transition high dose MME (>90MME) to buprenorphine. they usually do very well. hard part is the transition to buprenorphine. i dose depending on the amount but extremely high MMEs (200-300 or more) i put them on 8mg TID and most transition well. pts often state they get better pain relief. i titrate down as tolerated afterwards.
belbucca i think works well too but max dose is a bit lower (900mcg bid but equivalence a bit higher due to better absorption) . if i am thinking long acting opioid i think of belbucca + small breakthrough IR

 

[Ducttape]

if it is "not strong enough", you are dealing with an opioid tolerant patient that was probably previously on high MED treatment. technically, 20 mcg/hr is about 99MED...

belbuca is a nice treatment but not covered by a lot of insurances. like any, start low, titrate up slowly. i hate to invoke clinical experience here, but... seems liked better than butrans.

 

[BobBarker]

Certainly, with belbuca you don’t have the skin sensitivity and lack of efficacy past day 5.

 

[mazinger]

if it is "not strong enough", you are dealing with an opioid tolerant patient that was probably previously on high MED treatment. technically, 20 mcg/hr is about 99MED...

belbuca is a nice treatment but not covered by a lot of insurances. like any, start low, titrate up slowly. i hate to invoke clinical experience here, but... seems liked better than butrans.

Belbuca is great! Although, very cost prohibitive.
I wish I could prescribe this more..

 

[likeaboss]

can’t we just do good old fashioned subutex, break a 2mg tab in half and take that sublingual BID? how many morphine equivalents is this roughly?

also, i don’t have the certification for suboxone / buprenorphine for addiction but my understanding is i can prescribe them for pain, right?


anyway i’m really tired of these new expensive drugs that make it so hard to keep patients compliant

 

[Cholula]

20 mcg/hr Butrans is MED under or around 30. Belbuca can get to MED 54 at max dose (MED = 0.03 x total daily dose in mcg of Belbuca). I'll have to check my notes at my office on Monday for the Butrans conversion. Each preparation of buprenorphine has a different bioavailability thus different MED conversion. At these doses I don't think it comes close to saturating the receptors so some PRN opioids are still effective to use.

 

[Aether2000]

From a variety of sources: blood levels of various buprenorphine preparations

SINGLE DRUG Buprenorphine
Belbuca 75mg film- 0.17 ng/ml
Belbuca 600mg film- 0.76 ng/ml
Butrans 10mcg/hr patch- 0.19 ng/ml- falls to half of this on day 7
Butrans 20mcg/hr patch- 0.47 ng/ml- falls to half of this on day 7
Buprenorphine 2mg sublingual tabs- 1.25 ng/ml (Subutex- brand off market, generic available)
Buprenorphine 8 mg sublingual tabs- 2.88 ng/ml (Subutex- brand off market, generic available)
Buprenorphine 0.3mg IV injection (available clinically)- 2.1 ng/ml (calc)
Buprenorphine 2mg tabs intranasal (snorting)- 2.8 ng/ml Tmax 38 min
Buprenorphine 8mg tabs intranasal (snorting)- 11.2 ng/ml Tmax 35min
Buprenorphine 2mg IV injection (diversion of tablets)- 19.3 ng/ml- Tmax 10min
Buprenorphine 8mg IV injection (diversion of tablets)- 125 ng/ml- Tmax 10 min

COMBINATION Buprenophine/naloxone Generally Tmax ~ 3 hours
Suboxone generic tabs 2mg SL- 0.8ng/ml (est.)
Suboxone generic tabs 4mg SL- 1.9ng/ml
Suboxone generic tabs 8mg SL- 2.65ng/ml
Suboxone film 2mg – 1.1ng/ml (est)
Suboxone film 8mg - 3.0ng/ml (calc)
Zubsolv 1.4mg tabs SL- 0.8 ng/ml
Zubsolv 5.7mg tabs SL- 2.7ng/ml
Bunavail 2.1mg buccal films- 0.88 ng/ml
Bunavail 8.4mg buccal films- 3.0 ng/ml

 

[Ducttape]

thanks.

and from CMS:

https://www.cms.gov/Medicare/Prescr...Morphine-EQ-Conversion-Factors-March-2015.pdf

2 The MME conversion factor for buprenorphine patches is based on the assumption that one milligram of parenteral buprenorphine is equivalent to 75 milligrams of oral morphine and that one patch delivers the dispensed micrograms per hour over a 24 hour day. Example: 5 ug/hr buprenorphine patch * 24 hrs = 120 ug/day buprenorphine = 0.12 mg/day buprenorphine = 9 mg/day oral morphine milligram equivalent. In other words, the conversion factor not accounting for days of use would be 9/5 or 1.8. However, since the buprenorphine patch remains in place for 7 days, we have multiplied the conversion factor by 7 (1.8 X 7 = 12.6). In this example, MME/day for four 5 μg/hr buprenorphine patches dispensed for use over 28 days would work out as follows: Example: 5 ug/hr buprenorphine patch * (4 patches/28 days)* 12.6 = 9 MME/day.

 

[DocMorpheus]

What’s the consensus of patients on butrans or belbuca and breakthrough IR oxycodone or hydrocodone.

Patients are usually not seeing a benefit and pharmacologically it doesn’t make sense to mix the two to me - a) buprinorphine is so tightly bound, how can hydrocodone or oxycodone bind to the mu receptor and b) if you take buprinorphine after oxycodone, it will displace it and thus in both scenarios, the IR medication is kind of a waste

Would appreciate any insight.

 

[lobelsteve]

What’s the consensus of patients on butrans or belbuca and breakthrough IR oxycodone or hydrocodone.

Patients are usually not seeing a benefit and pharmacologically it doesn’t make sense to mix the two to me - a) buprinorphine is so tightly bound, how can hydrocodone or oxycodone bind to the mu receptor and b) if you take buprinorphine after oxycodone, it will displace it and thus in both scenarios, the IR medication is kind of a waste

Would appreciate any insight.

No blocking of btp meds. No ill effects. Butrans plasma levels not same as suboxone.

 

[Ducttape]

agree, but i prefer to use Nucynta or tramadol with butrans.

 

[Orin]

Even though buprenorphine binds stronger than most, it's just a competition for on/off with the other agents they're within the ballpark to comepte. There's also some complexity with off-target/non-mu mediated effects with both bupe and other agonists.

While I do lean on tramadol and tapentadol, I do have patients that report/show efficacy on buprenorphine mixed with PRN oxycodone or hydromorphone. That may be the patients that form a lot more oxymorphone for the oxycodone users, but it's something I try. For the intraoperative stuff, sufentanil binds stronger than buprenorphine, although fentanyl and remifentanil are in the wheelhouse for usage if needed.

For my ambulatory folks, I normally don't add the PRNs in until they're steady and showing benefit from a buprenorphine dosage.

 

[likeaboss]

In patients who have been on higher doses of opioids like 40-100MME can you just put them on sublingual buprenorphine 2mg tabs 1/2 tab BID? I did this recently with one of my patients and she did pretty well. This was for the management of pain / fibromyalgia. She has been on a 12mcg fent patch and Norco 10 qid for many years.

 

[kstarm]

I think these topics always come down to if you believe opioids for chronic non-cancer pain work or don't work. I would never consider opioids for fibromyalgia. When you switch to bupe in patients that have been on full agonist for years I think you need to at least consider that you are treating the fact that they have been on opioids for years and the brain changes that happen with that and not necessarily their initial pain issues anymore.