Is it okay to use Suboxone (buprenorphine/naloxone) and a Butran (buprenorphine) patch together?

Using Suboxone and Butran Patch Together Is Not Recommended

Using Suboxone (buprenorphine/naloxone) and a Butran (buprenorphine) patch together is not recommended due to the risk of duplicate therapy with the same active ingredient, which could lead to increased side effects without additional therapeutic benefit. 1

Pharmacology and Rationale

Both medications contain buprenorphine, a partial opioid agonist with high binding affinity for the μ-opioid receptor:

• Suboxone: Combination of buprenorphine and naloxone (4:1 ratio) in sublingual tablet/film form 2

  • Used primarily for opioid use disorder treatment
  • Contains naloxone to discourage misuse by injection

• Butran: Transdermal buprenorphine patch 3

  • Used primarily for chronic pain management
  • Delivers continuous buprenorphine through the skin

Risks of Concurrent Use

1. Duplicate therapy: Both medications deliver the same active ingredient (buprenorphine) 1

2. Unpredictable blood levels: Different delivery methods (sublingual vs. transdermal) make dosing unpredictable 3

3. Increased side effects: Higher risk of:

   • Respiratory depression (though buprenorphine has a ceiling effect) 1
   • Sedation
   • Constipation
   • Headache

4. Drug interactions: Both formulations can cause:

   • QT-interval prolongation 3
   • Serotonin syndrome
   • Paralytic ileus
   • Reduced analgesic effect 3

Alternative Approaches for Pain Management with Suboxone

If you're on Suboxone and experiencing pain, consider these evidence-based alternatives:

1. Adjust Suboxone dosing: Increase buprenorphine in divided doses (4-16mg in 8-hour doses) for better pain control 3, 1

2. Switch formulations: Consider switching from Suboxone to buprenorphine transdermal (Butran) alone rather than using both 3, 1

3. Add non-opioid pain management: Use adjuvant therapies appropriate to your pain syndrome 3

   • Nonopioid analgesics
   • Topical agents
   • Nonpharmacologic treatments

4. Consider potent opioids: If maximum buprenorphine dose is reached without adequate pain control, your provider might consider adding a long-acting potent opioid like fentanyl, morphine, or hydromorphone 3

5. Transition to methadone: For patients with inadequate pain control despite the above strategies, transitioning from buprenorphine to methadone maintenance may be considered 3

Important Considerations

• Consult your prescriber: Never combine these medications without medical supervision
• Avoid abrupt discontinuation: Stopping either medication suddenly can cause withdrawal
• Perioperative management: Special considerations apply during surgical periods 3
• Monitor for side effects: Watch for sedation, respiratory depression, and other adverse effects

Common Pitfalls to Avoid

• Self-adjusting doses: Never adjust doses without medical supervision
• Combining with other CNS depressants: Avoid benzodiazepines and alcohol which increase overdose risk
• Assuming more is better: Higher doses of buprenorphine don't necessarily provide better pain relief due to its partial agonist properties
• Improper disposal: Ensure proper disposal of patches to prevent accidental exposure to others

Remember that buprenorphine has unique properties that make it safer than full opioid agonists, but combining different formulations increases risks without clear benefits.