What is the role of Butrans (buprenorphine) patch in managing chronic pain?

From the Guidelines

Butrans (buprenorphine) transdermal patch is a viable option for managing moderate to severe chronic pain, particularly when around-the-clock analgesia is needed for extended periods, as it provides consistent pain relief with less potential for abuse and dependence compared to full opioid agonists, as noted in the 2017 HIVMA of IDSA clinical practice guideline for the management of chronic pain in patients living with HIV 1. The patch delivers a steady dose of buprenorphine, a partial opioid agonist, through the skin over 7 days. Butrans is typically prescribed in strengths ranging from 5 to 20 mcg/hour, with patients usually starting at the lowest effective dose and titrating as needed under medical supervision. Some key points to consider when using Butrans for chronic pain management include:

• The patch should be applied to clean, dry, non-irritated skin on the upper arm, upper chest, upper back, or side of the chest, with rotation of application sites to prevent skin irritation.
• Common side effects include nausea, headache, dizziness, constipation, and application site reactions.
• Butrans offers advantages including weekly application (improving compliance), lower risk of respiratory depression, a ceiling effect on euphoria (reducing abuse potential), and fewer withdrawal symptoms upon discontinuation.
• However, it should be used cautiously in opioid-naïve patients and is contraindicated in severe respiratory depression, acute or severe bronchial asthma, and known hypersensitivity to buprenorphine, as highlighted in the CDC guideline for prescribing opioids for chronic pain 1.
• Patients should be monitored regularly for effectiveness and side effects, with dose adjustments made as necessary, and nonpharmacologic therapy and nonopioid pharmacologic therapy should be considered as preferred treatments for chronic pain, as recommended by the CDC guideline 1.

From the FDA Drug Label

CLINICAL PHARMACOLOGY: Mechanism of Action: Buprenorphine exerts its analgesic effect via high affinity binding to various subclasses of opiate receptors, particularly mu, in the central nervous system. Pharmacokinetics: Following application of ZORBIUM, solvent evaporation coupled with the permeation enhancer action results in rapid absorption and sequestration of the buprenorphine into the skin. ZORBIUM provides analgesia within 1 – 2 hours following administration and continually releases buprenorphine from the skin into the systemic circulation over a period of days.

The Butrans patch works by exerting its analgesic effect via high affinity binding to mu opioid receptors in the central nervous system. It provides analgesia within 1-2 hours after administration and continually releases buprenorphine into the systemic circulation over a period of days 2.

• The role of Butrans in managing chronic pain is not explicitly stated in the provided drug labels, but it is indicated for the control of postoperative pain associated with surgical procedures in cats 2.
• The efficacy of the Butrans patch in managing chronic pain cannot be directly concluded from the provided information.

From the Research

Efficacy of Butrans Patch

• The Butrans patch, which contains buprenorphine, has been approved by the FDA for the treatment of moderate to severe chronic pain 3.
• Studies have shown that buprenorphine transdermal system (BTDS) is efficacious and generally well tolerated for the management of chronic moderate to severe low back pain 4.
• A review of 33 clinical studies found that buprenorphine was effective in pain relief and generally well tolerated, with 28 studies assessing safety and concluding that buprenorphine was safe to use 5.

Safety and Tolerability

• The incidence of treatment-emergent adverse events was 56% during the open-label period and 59,77, and 73% for the BTDS 5, BTDS 20, and oxycodone 40 mg/day treatment groups, respectively, during the double-blind phase 4.
• Buprenorphine has been found to be a safer alternative to traditional opioids, with less abuse potential and fewer side effects such as cognitive impairment, falls, and sexual dysfunction 6, 7.

Comparison to Other Opioids

• Buprenorphine has been compared to full μ-opioid receptor agonists and found to be an equally effective but potentially safer treatment option for chronic pain 5.
• A review found that buprenorphine may be associated with less cognitive impairment, falls, sexual dysfunction, and sarcopenia when compared with schedule II opioids, making it a good option for the elderly 6.

Clinical Use

• Buprenorphine has unique and favorable pharmacological properties that make it useful in a variety of clinical scenarios, including patients with comorbid substance use disorder or non-medical opioid use 6.
• The popularity of using buprenorphine for analgesia continues to grow, and it is considered an excellent and safe option for chronic pain 6, 7.