From the Guidelines
No, there is no standard protocol for substance use disorder treatment that involves using a Butrans patch (buprenorphine transdermal system) at 20 mg strength for three days followed by buprenorphine tablets on the fourth day. This approach would be problematic for several reasons. First, Butrans patches are FDA-approved for pain management, not for opioid use disorder (OUD), and their highest available strength is 20 mcg/hour (not 20 mg) 1. For OUD treatment, sublingual or buccal formulations like Suboxone or Subutex are used instead.
Key Considerations
- The standard protocol for initiating buprenorphine treatment for OUD involves starting with sublingual tablets or films when the patient is in mild to moderate withdrawal, typically beginning with 2-4 mg and titrating up as needed 1.
- Mixing delivery systems (transdermal to oral) could lead to unpredictable blood levels and potentially dangerous fluctuations in medication effect.
- Proper OUD treatment requires careful monitoring, especially during induction, which typically follows established protocols under medical supervision to ensure safety and effectiveness 1.
Clinical Implications
- Buprenorphine is a partial opioid agonist with a high binding affinity for the μ-opioid receptor, which is beneficial in the treatment of opioid use disorder 1.
- The dose of buprenorphine can be increased to provide additional analgesia, but it is essential to follow established protocols and guidelines to ensure safe and effective treatment 1.
- Clinicians should be aware of the potential risks and benefits of buprenorphine treatment and carefully monitor patients to minimize adverse effects and optimize outcomes 1.
From the Research
Buprenorphine Treatment Protocol
- The provided studies do not specifically mention a protocol for substance use disorder where a Butrans (buprenorphine) patch of 20 milligrams is used daily for three days, followed by initiation of buprenorphine tablets on the fourth day 2, 3, 4, 5, 6.
- However, the studies discuss various buprenorphine initiation protocols, including rapid overlap initiation and microdosing strategies, which may help reduce the risk of precipitated withdrawal and improve treatment tolerability 2, 3, 6.
- Buprenorphine is a effective and safe treatment for opioid use disorder, and its use in various formulations, including transdermal patches, sublingual tablets, and injectable formulations, has been studied 4, 5.
- The initiation of buprenorphine treatment should be based on the patient's patterns of opioid use and response to therapy, and caution is recommended to avoid precipitation of buprenorphine-induced opioid withdrawal 5, 6.
Key Considerations
- The risk of precipitated withdrawal is a significant concern when initiating buprenorphine treatment, and strategies such as waiting for the onset of moderate opioid withdrawal symptoms and using alternative dosing strategies may help prevent this complication 6.
- The use of buprenorphine in the emergency department setting has been shown to be effective and safe, and a multimodal medication-assisted treatment plan involving pharmacologic treatment, counseling, and behavioral therapy is essential to maintaining opioid remission 5.
- Establishing a buprenorphine program in the emergency department involves a multifactorial approach to establish a pro-buprenorphine culture, and evidence-based discussions on the safety and benefits of buprenorphine are essential to promoting a culture of acceptance and optimizing treatment 5.