buprenorphine or bust?

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GoBeers

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so... simple question. Given buprenorphine unique MoA and safer profile, as well as knowing chronic / escalating doses of opioids generally aren't great, is anyone essentially prescribing only buprenorphine at this point? seems like there is no reason to use any other opioid (cost and side effect issues aside). i've been converting more and more patients with success and now feel there isn't a big reason to use anything else
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Are you using only Belbuca and Butrans or also subutex/suboxone? I have tried getting as many old patients on Belbuca or Butrans as possible but there are definitely those that either cannot afford the "insurance-covered" medication, or have issues with the patch or film. They also generate a lot of post-clinic work with these issues (e.g. "patch fell off in the shower" or "belbuca is $400 a month") and this adds time to the end of the day. I will not prescribe an opioid agonist to those on benzodiazepines but have inherited the occasional patient that I do tell it is either buprenorphine or bust for them. I have a dot phrase that outlines the medical necessity of buprenorphine for the insurance company. Make sure the patient knows it is not a stepping stone to oxycodone/hydrocodone.
 
fathead88 said:
Are you using only Belbuca and Butrans or also subutex/suboxone? I have tried getting as many old patients on Belbuca or Butrans as possible but there are definitely those that either cannot afford the "insurance-covered" medication, or have issues with the patch or film. They also generate a lot of post-clinic work with these issues (e.g. "patch fell off in the shower" or "belbuca is $400 a month") and this adds time to the end of the day. I will not prescribe an opioid agonist to those on benzodiazepines but have inherited the occasional patient that I do tell it is either buprenorphine or bust for them. I have a dot phrase that outlines the medical necessity of buprenorphine for the insurance company. Make sure the patient knows it is not a stepping stone to oxycodone/hydrocodone.
Click to expand...
i prescribe belbuca, butrans and even buprenorphine SL. whichever is covered. buprenorphine SL i try to keep at 6mg / day or less , but typically it's 2mg bid.
 
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i still use some tramadol, some oxycodone, and some fentanyl along with belbuca and butrans.

each patient is unique and in certain circumstances, use of pure opioid agonist is the best treatment.
 
Ducttape said:
i still use some tramadol, some oxycodone, and some fentanyl along with belbuca and butrans.

each patient is unique and in certain circumstances, use of pure opioid agonist is the best treatment.
Click to expand...
yes, but why not start with buprenorphine, and then escalate as appropriate?
it just seems like a great tool i wish i used more in training
 
I have transitioned to mostly bupe. I am starting to try tapentadol more for appropriate patients. I have some inherited patients on oxy which most are working on tapering. Some tramadol. No methadone or fentanyl currently. If I get more cancer patients I may do more with those medications.
 
GoBeers said:
yes, but why not start with buprenorphine, and then escalate as appropriate?
it just seems like a great tool i wish i used more in training
Click to expand...
one simple reason - because certain patients do not need constant opioid therapy.

certain patients may take 3 tramadol a day, or maybe an oxycodone once every day or so. it is not appropriate in those cases to have someone take an opioid that has 24/7 effect, for transient pain.

other reasons - cost, ease of use, ceiling effect from buprenorphine

buprenorphine is a great drug. but patient criteria factor in to what is the best drug for them. buprenorphine is not one drug to cover all conditions
 
GoBeers said:
so... simple question. Given buprenorphine unique MoA and safer profile, as well as knowing chronic / escalating doses of opioids generally aren't great, is anyone essentially prescribing only buprenorphine at this point? seems like there is no reason to use any other opioid (cost and side effect issues aside). i've been converting more and more patients with success and now feel there isn't a big reason to use anything else
Click to expand...

The Suboxone reps were so generous and helpful at educating prescribers back in the day. Wonderful journal clubs at interesting locations with thoughtfully selected menus and stimulating conversation.
 
drusso said:
The Suboxone reps were so generous and helpful at educating prescribers back in the day. Wonderful journal clubs at interesting locations with thoughtfully selected menus and stimulating conversation.
Click to expand...
In my area Belbuca reps have filled this serious void.
 
I have used buprenorphine much more as a first line - Belbuca and Butrans.
 
GoBeers said:
yes, but why not start with buprenorphine, and then escalate as appropriate?
it just seems like a great tool i wish i used more in training
Click to expand...

1. Really old people don't need 24/7 pain medication to be functional and active with ADL's
2. Patch falls off in summer if active. Difficult to shower, bathe with patch on
3. Many insurances will not cover Belbuca. Even if they do, out of pocket cost is prohibitive
4. Medicaid patients can't get high on Belbuca or Butrans, so they will refuse it or make up side effect problems once on it
5. Medicaid patients can't sell Belbuca or Butrans, so they will refuse it or make up side effect problems once on it
6. Belbuca sticks to teeth, lower functioning patients have difficulty adapting to it
7. Insurances only give 4 patches/month, usually by day 5-6 patch is ineffective or held with duct tape (not the SDN poster).
8. Many Belbuca patients end up escalating over time to SL Buprenorphine.

I am a buprenorphine fan, but over the years I've come to realize it's limitations too. If you have continuous longitudinal follow up with your patients you will discover some of these problems crop up over the long term.

It's the drug most appropriate for Medicaid patients with chronic pain but it is the one they want the least
 
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It would suck to be on butrans and get in a wreck, femur fracture, and know that the fentanyl EMS is pushing won’t do a d—- thing
 
tmvguy03 said:
It would suck to be on butrans and get in a wreck, femur fracture, and know that the fentanyl EMS is pushing won’t do a d—- thing
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Yes it will. Butrans doesn't block much.

Hell, current anesthesia guidelines say to continue Suboxone during perioperative period.
 
tmvguy03 said:
It would suck to be on butrans and get in a wreck, femur fracture, and know that the fentanyl EMS is pushing won’t do a d—- thing
Click to expand...

Really outdated myth. Take a look at this chart and keep in mind that max dose butrans is 20 mcg/hr.
 

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I try to use bupe and nucynta as my primary opioids, but get a lot of concerns about out of pocket cost, even though they're "covered". I end up with many of these patients on Norco because they can afford it.
Also had a really interesting experience with Butrans a few months ago: pt was on oxy 10 tid, wasn't working, pain was 10/10 on initial visit. Started her on Butrans, and at both her 1 week f/u (required in TX for new controlled rx) and her 1 month f/u, she was singing my praises. "this stuff is amazing! I didn't know I could have so little pain!" She got her first refill, incidentally a different brand generic from the first rx, and developed terrible N/V. UDS showed no other substances in her system. Hassled with pharmacy and insurance, and finally got brand Butrans approved - still terrible. Switched to subutex. Still with N/V, also "made me feel stoned". Finally switched her up to T3. I have no idea what happened with her.
 
fathead88 said:
Are you using only Belbuca and Butrans or also subutex/suboxone? I have tried getting as many old patients on Belbuca or Butrans as possible but there are definitely those that either cannot afford the "insurance-covered" medication, or have issues with the patch or film. They also generate a lot of post-clinic work with these issues (e.g. "patch fell off in the shower" or "belbuca is $400 a month") and this adds time to the end of the day. I will not prescribe an opioid agonist to those on benzodiazepines but have inherited the occasional patient that I do tell it is either buprenorphine or bust for them. I have a dot phrase that outlines the medical necessity of buprenorphine for the insurance company. Make sure the patient knows it is not a stepping stone to oxycodone/hydrocodone.
Click to expand...

Care to share the dot phrase ?
 
ateria radicularis magna said:
Care to share the dot phrase ?
Click to expand...
- Buprenorphine was chosen for this patient as a medically necessary choice for analgesia in lieu of schedule II traditional opioid agonists given its improved safety profile and schedule III status. Buprenorphine's safety is conferred by a ceiling effect, flattening of the dose/response curve for respiratory depression. While this does not totally obviate the risk of overdose and catastrophic respiratory depression when combined with other sedating medications (including benzodiazepines, gabapentinoids, and other sleep aids), the risk has found to be significantly diminished.

I am not sure if it makes any difference in getting it covered, but I put this in every note for patients that are prescribed it.
 
I use the following when I get the insurance company telling me that my 85lb 85yo needs to do methadone or fentanyl before trying bupe (I know the reference is a little dated)...I bold the important parts for them


Pergolizzi, J., Böger, R. H., Budd, K., Dahan, A., Erdine, S., Hans, G., Kress, H.-G., Langford, R., Likar, R., Raffa, R. B. and Sacerdote, P. (2008), Opioids and the Management of Chronic Severe Pain in the Elderly: Consensus Statement of an International Expert Panel with Focus on the Six Clinically Most Often Used World Health Organization step III Opioids (Buprenorphine, Fentanyl, Hydromorphone, Methadone, Morphine, Oxycodone). Pain Practice, 8: 287–313. doi:10.1111/j.1533-2500.2008.00204.x

4.The use of opioids in elderly patients with impaired hepatic and renal function:? Functional impairment of excretory organs is common in the elderly, especially with respect to renal function. For all opioids except buprenorphine, half-life of the active drug and metabolites is increased in the elderly and in patients with renal dysfunction. It is, therefore, recommended that—except for buprenorphine—doses be reduced, a longer time interval be used between doses, and creatinine clearance be monitored. Thus, buprenorphine appears to be the top-line choice for opioid treatment in the elderly.

5.Opioids and respiratory depression:? Respiratory depression is a significant threat for opioid-treated patients with underlying pulmonary condition or receiving concomitant central nervous system (CNS) drugs associated with hypoventilation. Not all opioids show equal effects on respiratory depression: buprenorphine is the only opioid demonstrating a ceiling for respiratory depression when used without other CNS depressants. The different features of opioids regarding respiratory effects should be considered when treating patients at risk for respiratory problems, therefore careful dosing must be maintained.

6.Opioids and immunosuppression:? Age is related to a gradual decline in the immune system: immunosenescence, which is associated with increased morbidity and mortality from infectious diseases, autoimmune diseases, and cancer, and decreased efficacy of immunotherapy, such as vaccination. The clinical relevance of the immunosuppressant effects of opioids in the elderly is not fully understood, and pain itself may also cause immunosuppression.

Providing adequate analgesia can be achieved without significant adverse events, opioids with minimal immunosuppressive characteristics should be used in the elderly. The immunosuppressive effects of most opioids are poorly described and this is one of the problems in assessing true effect of the opioid spectrum, but there is some indication that higher doses of opioids correlate with increased immunosuppressant effects. Taking into consideration all the very limited available evidence from preclinical and clinical work, buprenorphine can be recommended, while morphine and fentanyl cannot.
 
GoBeers said:
i prescribe belbuca, butrans and even buprenorphine SL. whichever is covered. buprenorphine SL i try to keep at 6mg / day or less , but typically it's 2mg bid.
Click to expand...
I recommend including dental decay in your patient agreement if using these sl buprenorphine products. The dental literature is reporting carries from oral buprenorphine
 
SpineBound said:
I recommend including dental decay in your patient agreement if using these sl buprenorphine products. The dental literature is reporting carries from oral buprenorphine
Click to expand...

Certainly reasonable to protect oneself during consent. Is there anything particularly compelling in the dental literature from what you've seen? Based on the case numbers from the FDA Drug Safety Communication the n is tiny...to the point that the risk of dental decay from a fruit rollup is probably many times greater than sl bup.
 
au bon pain said:
Certainly reasonable to protect oneself during consent. Is there anything particularly compelling in the dental literature from what you've seen? Based on the case numbers from the FDA Drug Safety Communication the n is tiny...to the point that the risk of dental decay from a fruit rollup is probably many times greater than sl bup.
Click to expand...
Yeah it’s tiny so don’t bother sucking on it then
 
fathead88 said:
Are you using only Belbuca and Butrans or also subutex/suboxone? I have tried getting as many old patients on Belbuca or Butrans as possible but there are definitely those that either cannot afford the "insurance-covered" medication, or have issues with the patch or film. They also generate a lot of post-clinic work with these issues (e.g. "patch fell off in the shower" or "belbuca is $400 a month") and this adds time to the end of the day. I will not prescribe an opioid agonist to those on benzodiazepines but have inherited the occasional patient that I do tell it is either buprenorphine or bust for them. I have a dot phrase that outlines the medical necessity of buprenorphine for the insurance company. Make sure the patient knows it is not a stepping stone to oxycodone/hydrocodone.
Click to expand...
Don't have the details here as I'm not in the office today, but there are multiple discount programs for butrans. I tell my patients as I prescribe that there is a very high chance their insurance will not cover this and if so, that doesn't mean they will now be prescribed a pure opioid, but it means that 1- their insurance company are idiots, 2- the patient will have to pay out of pocket, and with the these discount cards/codes, this cost will be around $50-70 dollars. I tell them all this in the room in a way that the patient is surprised if their insurance company covers butrans, and if they don't , then the $50-70 monthly cost is not a surprise, and my staff and I don't waste time on phone calls.

Now that butrans is generic (and there are discount cards/codes that your local pharmacist can provide for you) there is no reason for anyone to be prescribed a pure opioid due to cost. If you are in pain you will find $50 a month to pay for butrans, its not $5000 a month.
 
Last edited:
Centurion38 said:
1. Really old people don't need 24/7 pain medication to be functional and active with ADL's
2. Patch falls off in summer if active. Difficult to shower, bathe with patch on
3. Many insurances will not cover Belbuca. Even if they do, out of pocket cost is prohibitive
4. Medicaid patients can't get high on Belbuca or Butrans, so they will refuse it or make up side effect problems once on it
5. Medicaid patients can't sell Belbuca or Butrans, so they will refuse it or make up side effect problems once on it
6. Belbuca sticks to teeth, lower functioning patients have difficulty adapting to it
7. Insurances only give 4 patches/month, usually by day 5-6 patch is ineffective or held with duct tape (not the SDN poster).
8. Many Belbuca patients end up escalating over time to SL Buprenorphine.

I am a buprenorphine fan, but over the years I've come to realize it's limitations too. If you have continuous longitudinal follow up with your patients you will discover some of these problems crop up over the long term.

It's the drug most appropriate for Medicaid patients with chronic pain but it is the one they want the least
Click to expand...

I agree that old patients don't need 24/7 meds. I will allow such patients BID dosing of a standard low dose opioid. But if they have to continually escalate the strength, or want a third daily dose, then they get switched to butrans.

For 99% of medicaid patients, I would not prescribe a standard opioid. It's butrans or nothing. If they don't like it, too bad, they can go to another doctor.
 
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bedrock said:
I agree that old patients don't need 24/y7 meds. I will allow such patients BID dosing of a standard low dose opioid. But if they have to continually escalate the strength, or want a third daily dose, then they get switched to butrans.

For 99% of medicaid patients, I would not prescribe a standard opioid. It's butrans or nothing. If they don't like it, too bad, they can go to another doctor.
Click to expand...
What percentage of your practice is Medicaid?
 
bedrock said:
Don't have the details here as I'm not in the office today, but there are multiple discount programs for butrans. I tell my patients as I prescribe that there is a very high chance their insurance will not cover this and if so, that doesn't mean they will now be prescribed a pure opioid, but it means that 1- their insurance company are idiots, 2- the patient will have to pay out of pocket, and with the these discount cards/codes, this cost will be around $50-70 dollars. I tell them all this in the room in a way that the patient is surprised if their insurance company covers butrans, and if they don't , then the $50-70 monthly cost is not a surprise, and my staff and I don't waste time on phone calls.

Now that butrans is generic (and there are discount cards/codes that your local pharmacist can provide for you) there is no reason for anyone to be prescribed a pure opioid due to cost. If you are in pain you will find $50 a month to pay for butrans, its not $5000 a month.
Click to expand...
Any more details on the Butrans discounts? My searches have come up short
 
Baron Samedi said:
Really outdated myth. Take a look at this chart and keep in mind that max dose butrans is 20 mcg/hr.
Click to expand...
Thank you for this- I learned something new today, and could positively affect my practice
Ferrismonk said:
Yes it will. Butrans doesn't block much.

Hell, current anesthesia guidelines say to continue Suboxone during perioperative period.
Click to expand...
I also didn’t know this. I appreciate the knowledge 👍
 
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