What is the recommended protocol for transitioning a patient from oral narcotics to Butrans (buprenorphine)?

Transitioning from Oral Narcotics to Butrans (Buprenorphine)

When transitioning a patient from oral narcotics to Butrans (transdermal buprenorphine), use a novel method that avoids the traditional opioid-free withdrawal period by applying the transdermal patch while the patient is still taking their oral opioids, then gradually tapering the oral medication. 1

Understanding Buprenorphine Properties

Buprenorphine is a partial mu-opioid agonist with unique pharmacological properties:

• High binding affinity to opioid receptors
• Ceiling effect for respiratory depression
• Effective for neuropathic pain and hyperalgesic states
• Less immune and endocrine system suppression compared to other long-acting opioids 1

Conversion Protocol

Step 1: Initial Assessment and Preparation

• Verify the patient's current daily oral opioid dose and calculate the morphine equivalent daily dose (MEDD)
• Use standard conversion ratios to determine appropriate Butrans patch strength 2
• For example:
  • 60mg oral morphine daily ≈ 25 mcg/h Butrans patch
  • 120mg oral morphine daily ≈ 50 mcg/h Butrans patch
  • 180mg oral morphine daily ≈ 75 mcg/h Butrans patch

Step 2: Initiation of Butrans

• Apply the Butrans patch while the patient is still taking their oral opioids
• Do not require an opioid-free period before starting Butrans 1
• Start with the appropriate patch strength based on MEDD calculations

Step 3: Tapering Oral Opioids

• Begin tapering oral opioids 24 hours after Butrans application
• Reduce oral opioid dose by 25-50% every 2-3 days
• Complete discontinuation of oral opioids within 7-14 days

Step 4: Monitoring and Adjustment

• Assess pain control and withdrawal symptoms every 24-48 hours
• If pain control is inadequate after 72 hours, consider increasing to the next patch strength 2
• Provide short-acting non-opioid analgesics for breakthrough pain during transition

Special Considerations

Managing Withdrawal Symptoms

• The traditional approach requiring 12-48 hours of opioid abstinence before buprenorphine initiation is unnecessary with this method 1
• Using Butrans as a "bridge" medication minimizes the risk of precipitated withdrawal
• If mild withdrawal symptoms occur, they can be managed with supportive care:
  • Clonidine for autonomic symptoms
  • Loperamide for gastrointestinal symptoms
  • NSAIDs or acetaminophen for pain/discomfort

Patient Education

• Explain that Butrans is a 7-day patch that provides continuous medication delivery
• Inform patients that full analgesic effect may take 24-48 hours to develop
• Advise patients not to use additional opioids unless specifically prescribed
• Instruct on proper patch application and disposal

Potential Challenges and Solutions

Inadequate Pain Control

• If pain control is inadequate with maximum Butrans dose:
  • Consider multimodal analgesia (NSAIDs, acetaminophen, adjuvant medications)
  • Evaluate for non-opioid pain management options
  • Consider referral to pain specialist

Side Effect Management

• Common side effects include headache, dizziness, somnolence, constipation, dry mouth, nausea, and application site reactions 3
• Prophylactic bowel regimen is recommended (stimulant laxative with or without stool softener) 4
• Transdermal buprenorphine has better tolerability profile than sublingual buprenorphine 5

Follow-up Care

• Schedule follow-up within 1-2 weeks of transition
• Assess pain control, functional status, and side effects
• Make dose adjustments as needed based on patient response
• Document pain assessment and rationale for any dose changes

This approach avoids the painful abstinence period traditionally required when initiating buprenorphine and has not been shown to result in precipitated withdrawal or other significant adverse effects in patients transitioning from short-acting opioids 1.