Buprenorphine (Butrans) Patch Dosage and Administration for Chronic Pain Management
Buprenorphine transdermal patches should be initiated at 5 μg/h for opioid-naïve patients and applied once weekly to clean, dry, intact skin, with dose adjustments made no more frequently than every 72 hours based on pain control. 1, 2
Dosing Protocol
- Start with 5 μg/h patch for opioid-naïve patients with chronic pain, with available strengths of 5,10, and 20 μg/h 2
- Apply patch to clean, dry, non-irritated, non-irradiated skin on upper outer arm, upper chest, upper back, or side of chest 1
- Change patch every 7 days (once weekly) 2, 3
- Titrate dose based on pain control, with dose adjustments no more frequently than every 72 hours 1, 4
- Maximum recommended dose is 20 μg/h for chronic non-malignant pain 2, 4
Converting from Other Opioids
- When converting from other opioids to buprenorphine patch, first calculate the 24-hour analgesic requirement of the current opioid 5
- Ensure pain is relatively well controlled on short-acting opioids before initiating the patch 5
- Due to buprenorphine's partial agonist properties, initiate the patch when the patient is experiencing mild withdrawal symptoms if transitioning from full μ-opioid agonists 1
- Use equianalgesic conversion tables to determine appropriate starting dose 5
Management of Breakthrough Pain
- Consider adding non-opioid adjuvant therapies such as NSAIDs or acetaminophen for breakthrough pain rather than short-acting opioids 1
- An as-needed dose of short-acting opioid may be needed particularly during the first 8-24 hours after patch application 5
- After steady state is reached (2-3 days), adjust patch dosage based on the average amount of daily breakthrough medication required 5
Special Considerations
- Buprenorphine has a ceiling effect for respiratory depression, making it potentially safer than full opioid agonists 1, 6
- No dosage adjustments needed for elderly patients or those with compromised renal function 2
- Avoid application of heat (e.g., fever, heat lamps, electric blankets) as it may accelerate transdermal absorption 5
- Monitor for common side effects including nausea (30.4%), constipation (18.8%), dizziness (15.9%), application site reactions, and pruritus 4, 3
Inadequate Pain Control
- If pain control is inadequate with the maximum transdermal dose (20 μg/h), consider adding adjuvant therapies 1
- For patients with persistent inadequate analgesia, consider transitioning to alternative pain management strategies 1
- Buprenorphine's high binding affinity for μ-opioid receptors may block effects of other opioids if given concurrently 1
Discontinuation
- Never stop buprenorphine abruptly 5
- Dose reduction should be in steps of 30-50% over about a week, depending on the clinical situation 5
Buprenorphine transdermal patches provide effective analgesia with the convenience of once-weekly administration and have demonstrated good efficacy and tolerability in clinical trials for chronic non-malignant pain 2, 4, 3.