Is there a protocol for using Butrans (buprenorphine) 20 microgram patches consecutively for three days, followed by buprenorphine sublingual tablets on the fourth day?

From the Guidelines

There is no standard protocol for using Butrans 20 μg patches consecutively for three days followed by sublingual buprenorphine tablets on the fourth day, and this approach is not recommended due to potential risks of inconsistent blood levels, withdrawal symptoms, or inadequate treatment. The proposed regimen is not supported by the available evidence, which emphasizes the importance of careful planning and monitoring when transitioning between buprenorphine formulations 1.

Key Considerations

• The different formulations of buprenorphine have distinct pharmacokinetics, with transdermal patches providing slow, steady release and sublingual tablets offering more rapid absorption and higher peak concentrations 1.
• Transitioning between formulations should be done under close medical supervision, taking into account the patient's specific condition, opioid tolerance, and treatment goals 1.
• The available evidence suggests that standard protocols typically involve either using Butrans patches continuously for 7 days as prescribed for pain management, or following specific induction protocols when transitioning patients to sublingual buprenorphine for opioid use disorder 1.

Potential Risks

• Inconsistent blood levels of buprenorphine
• Withdrawal symptoms
• Inadequate treatment
• Adverse effects

Recommendations

• Carefully plan any transition between buprenorphine formulations with appropriate dosing adjustments and monitoring for withdrawal symptoms or adverse effects 1.
• Consider the patient's specific condition, opioid tolerance, and treatment goals when making decisions about buprenorphine formulation and dosing 1.
• Follow established protocols and guidelines for the management of chronic pain and opioid use disorder, such as those outlined in the 2017 HIVMA of IDSA clinical practice guideline for the management of chronic pain in patients living with HIV 1.

From the Research

Buprenorphine Protocol

• The use of Butrans (buprenorphine) 20 microgram patches consecutively for three days, followed by buprenorphine sublingual tablets on the fourth day, is a protocol that has been explored in the context of opioid rotation and management of chronic pain or opioid use disorder 2.
• This approach is based on the concept of using transdermal buprenorphine as a bridge medication to avoid the painful abstinence period and precipitated withdrawal associated with the initiation of sublingual buprenorphine 2.
• Studies have shown that this method can be effective in avoiding precipitated withdrawal and other significant adverse effects, and can be a useful strategy for patients who are transitioning from full-agonist opioids to buprenorphine 2, 3.

Rationale and Evidence

• The rationale behind this protocol is to take advantage of the unique pharmacological properties of buprenorphine, including its partial opioid agonist activity and its ability to displace full agonists from the μ-opioid receptor 4, 2.
• The use of transdermal buprenorphine as a bridge medication can help to minimize the risk of precipitated withdrawal and facilitate a smoother transition to sublingual buprenorphine 2, 3.
• While the specific protocol of using Butrans 20 microgram patches for three days followed by sublingual buprenorphine on the fourth day is not universally established, the concept of using transdermal buprenorphine as a bridge medication is supported by the literature 2, 3.

Clinical Considerations

• The decision to use this protocol should be made on a case-by-case basis, taking into account the individual patient's medical history, current opioid regimen, and other relevant factors 2, 3.
• Patients should be closely monitored for signs of precipitated withdrawal, and the dose and duration of the transdermal buprenorphine should be adjusted as needed to minimize the risk of adverse effects 2, 5.