generic butrans finally!

[bedrock]

Really happy about this---

Teva intros authorized Butrans generic

I use a fair amount of butrans but often get pushback from patients due to the cost, so this will help a lot as for those I think need butrans, such as the pulmonary compromised, this is the only long-acting opioid I'm ever going to write for them........

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[Aether2000]

It is my hope the pricing does not resemble that of skelaxin when it went generic- 90% of the brand name cost. Fentanyl generic was the same- initially 90-95% of the name brand cost. When the first generic hits the market, the manufacturer is granted a period of time, usually 6 months, of exclusivity to market the generic, then other generics may enter the market. During that early period, the prices are usually high since there is no real competition other than the name brand. Once there are 3-4 manufacturers on the market, the price begins to drop significantly. If there remain only two manufacturers (name brand and generic), the price remains high for the generic.

 

[bedrock]

It is my hope the pricing does not resemble that of skelaxin when it went generic- 90% of the brand name cost. Fentanyl generic was the same- initially 90-95% of the name brand cost. When the first generic hits the market, the manufacturer is granted a period of time, usually 6 months, of exclusivity to market the generic, then other generics may enter the market. During that early period, the prices are usually high since there is no real competition other than the name brand. Once there are 3-4 manufacturers on the market, the price begins to drop significantly. If there remain only two manufacturers (name brand and generic), the price remains high for the generic.

Algos, you are correct regarding how the generic market works. Great explanation.
Also, I checked and the cost of generic butrans is only 20% less than the trade name for now.

Once other manufactures come on board next year, I expect that to decrease further. However, I've already seen better coverage by insurance companies this month with just the 20% drop in price of the generic. I've had patients with a particular mediocre insurance denied last year for trade name butrans, but just this week a patient on the same insurance was able to get generic butrans filled, as the very first opioid script for that patient with his insurance company.
I also had a patient who got a letter from a different insurance just one month ago stated they would not longer cover butrans, but in the intervening 4 weeks while her supply ran out, the generic came out and low and behold, the generic butrans was covered by her insurance this week.

So some progress in insurance coverage. Next year, I hope it will be much better for patients with worse insurance, so that getting coverage for generic butrans will be as easy as ER morphine.

 

[painfree23]

Really happy about this---

Teva intros authorized Butrans generic

I use a fair amount of butrans but often get pushback from patients due to the cost, so this will help a lot as for those I think need butrans, such as the pulmonary compromised, this is the only long-acting opioid I'm ever going to write for them........

Don't use much of this..how do start the dosing normally ? Usually on pts ur worried about abuse potential with po?

 

[lobelsteve]

Start 5mcg, increase 5mcg per month as needed to max of 20.
4 patches per month.

Use it in everybody at risk or even if not at risk.
C3 makes it easier, 4 patches makes it so overdose by applying all 4 is highly unlikely.
Mechanism is not pure agonist, so helps people when Norco or Percocet failed (in some cases).

Still opiate.

 

[Ducttape]

agree, except it is technically 4 patches per 28 days... 😎

particularly for those at risk, COPD, OSA, start low. I do use their conversion chart too. butrans.com.

2 major complaints (besides "not as good a high as Norco")
1. patches cause rash. try pretreating with Flonase.
2. patches wear out. try cutting dose and have patient put on 2 lower dose paches and "alternate" (ie for 10 mcg/hr, 2 of the 5 mcg/hr patch, put one on and the other 4 days later)

 

[melancholy]

As I sometimes have patients who have a hard time with skin irritation or adhesion with Fentanyl patches for even 48-72 hours (esp during summer), how do people keep these things on for a week? Is the adhesion that different.. maybe more like a catapres patch which is also weekly?

you can cut these patches? I know some are reservoir-membrane systems while others are matrix which can make a difference although I think for all the fentanyl patches regardless of system, they instruct to not cut the patches.

 

[Tapspatellas]

As I sometimes have patients who have a hard time with skin irritation or adhesion with Fentanyl patches for even 48-72 hours (esp during summer), how do people keep these things on for a week? Is the adhesion that different.. maybe more like a catapres patch which is also weekly?

you can cut these patches? I know some are reservoir-membrane systems while others are matrix which can make a difference although I think for all the fentanyl patches regardless of system, they instruct to not cut the patches.

Tell them to buy Bioclusive dressings off amazon to help keep the fent patches on. They are basically like a tegaderm, but from what I understand is the only one that they say is fine to use to cover the patch. The manufacturers used to give them out for free when people would call and complain.

 

[melancholy]

Tell them to buy Bioclusive dressings off amazon to help keep the fent patches on. They are basically like a tegaderm, but from what I understand is the only one that they say is fine to use to cover the patch. The manufacturers used to give them out for free when people would call and complain.

I recall patients can call the company to get coverlets but don't know if anyone has actually gotten them. I usually recommend tegaderm patches but will look at this bioclusive dressing. Thanks for the reference

Another issue is more of the skin irritation they get since skin doesn't really breathe esp w an occlusive dressing on. Do butrans patch patients ever have this issue before the weekly change?


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[Ducttape]

yes. see above. try to pretreat site with Flonase.

official company policy is that you cannot cut the patches. I looked in to that when trying to wean someone.

 

[Tapspatellas]

Another issue is more of the skin irritation they get since skin doesn't really breathe esp w an occlusive dressing on. Do butrans patch patients ever have this issue before the weekly change?

It doesn't seem to be the adhesive in the patch as well. If you look at the size of the square, it is the middle of the patch. Do the pre-treat with Flonase, then hydrocortisone for 2 days after if still an issue, seems to work for the few I've had.

 

[bedrock]

Don't use much of this..how do start the dosing normally ? Usually on pts ur worried about abuse potential with po?

dosing per steves post, at least for opioid naive patients. Start with 10mcg for patients on chronic opioids. but be ready to increase further promptly if they tolerate that initial dose without side effects, but have significant persistent pain.

butrans classically good for patients with breathing issues, COPD, etc, or for patients with abuse potential who need a long acting opioid. In reality the first two are true, but I would use butrans as my initial ER opioid of choice for all patients if it had the same insurance coverage as ER morphine.

Not only do you avoid the peaks and valleys of ER morphine and particularly Oxycontin, but you also give the patient something with far less abuse potential than a standard opioid and also there is decent data to support butrans over other ER opioids because of the reduced degree of opioid tolerance patients get with butrans as a partial agonist/antagonist compared to all other ER opiods.
The downside to butrans are the intermittent skin issues you have to be aware of and pretreat with topical flonase or hydrocortisone. Hopefully the generic butrans will use a different skin adhesive.

Butrans would literally be my first choice for an ER opioid for all patients if it had the same insurance coverage as ER morphine, which I expect it will achieve about 12 months from now.

 

[Aether2000]

Once you are beyond 40mg MED, switching to Butrans (or generic equivalent) is a lost cause for most patients since it will not have sufficient activation of the mu receptor. Butrans works best in opioid naive patients. Switching a patient on oxycontin at a dose above 10mg BID to Butrans will usually result in failure.

 

[Aether2000]

Here is a table of buprenorphine blood levels I obtained from many different sources and you can see butrans produces rather low blood levels- a 20mcg/hr patch yields blood levels around 15% of the 8mg Suboxone or equivalent. Note the non-linearity of buprenorphine with increasing doses- for instance butrans 20mg produces 247% the blood level of butrans 10mg. Suboxone 8mg produces 331% the blood level as 2mg Suboxone. I cross posted this in another forum.

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 – 1.1 ng/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

 

[bedrock]

Once you are beyond 40mg MED, switching to Butrans (or generic equivalent) is a lost cause for most patients since it will not have sufficient activation of the mu receptor. Butrans works best in opioid naive patients. Switching a patient on oxycontin at a dose above 10mg BID to Butrans will usually result in failure.

Agree that the doses of butrans availabe in the US are rather low compared to europe where you can get patches of 60mcg or more. Agree it's often difficult to switch to butrans from a high dose opiod, which is why I'm happy about generic butrans, because I want butrans to be the first ER opioid i write for a patient, not the third one, because it often fails in that situation.

Here is a table of buprenorphine blood levels I obtained from many different sources and you can see butrans produces rather low blood levels- a 20mcg/hr patch yields blood levels around 15% of the 8mg Suboxone or equivalent. Note the non-linearity of buprenorphine with increasing doses- for instance butrans 20mg produces 247% the blood level of butrans 10mg. Suboxone 8mg produces 331% the blood level as 2mg Suboxone. I cross posted this in another forum.

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 – 1.1 ng/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

Thank you, very helpful chart

 

[painfree23]

Start 5mcg, increase 5mcg per month as needed to max of 20.
4 patches per month.

Use it in everybody at risk or even if not at risk.
C3 makes it easier, 4 patches makes it so overdose by applying all 4 is highly unlikely.
Mechanism is not pure agonist, so helps people when Norco or Percocet failed (in some cases).

Still opiate.

Do you ever initiate therapy with butrans, instead of having to fail norco or Percocet. What patient populations do u avoid it in?

 

[lobelsteve]

Do you ever initiate therapy with butrans, instead of having to fail norco or Percocet. What patient populations do u avoid it in?

I believe butrans has a safety profile that makes it a better choice than any conventional opiate. If I risk stratify anyone in the medium to high risk they will not get anything but butran or Tramadol or both. If that doesn't work for them or if they still violate policy or are not meeting functional goals and then we just stopped medicines and see what else can be done.