How to switch a patient from hydrocodone (opioid analgesic) 5mg every 4-6 hours to Butrans (buprenorphine) patch?

Switching from Hydrocodone 5mg to Butrans Patch

To safely switch a patient from hydrocodone 5mg every 4-6 hours to Butrans (buprenorphine) transdermal patch, calculate the total daily hydrocodone dose and convert to an equivalent Butrans patch strength of 5-10 μg/h, ensuring overlap during the transition period to prevent withdrawal symptoms.

Dose Calculation and Conversion

• Calculate the total 24-hour hydrocodone dose:

  • Hydrocodone 5mg taken every 4 hours = 30mg/day
  • Hydrocodone 5mg taken every 6 hours = 20mg/day 1

• Based on clinical trials, patients taking 15-30mg of hydrocodone daily can be safely converted to either:

  • Butrans 10 μg/h (titratable approach) or
  • Butrans 20 μg/h (fixed-dose approach) 2

• For most patients on hydrocodone 5mg q4-6h, starting with Butrans 5-10 μg/h is appropriate to minimize side effects while maintaining pain control 3

Transition Protocol

1. Initial Application:

   • Apply the Butrans patch to clean, dry, non-irritated, non-hairy skin on the upper back, upper chest, side of chest, or upper outer arm 1
   • Continue the hydrocodone for the first 24 hours after applying the patch to maintain analgesia 1

2. Tapering Hydrocodone:

   • Gradually reduce hydrocodone dose over 24-48 hours as the buprenorphine reaches steady state 4
   • Steady state plasma concentrations are typically reached within 48 hours of the first Butrans application 4

3. Patch Management:

   • Change the Butrans patch every 7 days 5
   • Apply the new patch to a different skin site 1

Monitoring and Dose Adjustment

• Assess pain control 48-72 hours after the first patch application 4
• If pain relief is inadequate, consider titrating to a higher strength patch (10 μg/h to 20 μg/h) 2
• Provide breakthrough pain medication during the transition period as needed 1

Special Considerations

• Buprenorphine is a partial opioid agonist with high binding affinity for μ-opioid receptors, providing analgesia over a long period 1
• The transdermal formulation provides consistent and sustained delivery of buprenorphine with fewer side effects than oral opioids 6, 4
• Buprenorphine has a ceiling effect on respiratory depression, potentially making it safer than full agonist opioids 1

Common Pitfalls and Cautions

• Avoid applying heat (heating pads, electric blankets) to the patch site as this may accelerate absorption 1
• Monitor for typical opioid side effects, especially during the first week (nausea, dizziness, constipation) 3
• Be aware that concomitant use of buprenorphine with QT-prolonging agents is contraindicated 1
• Local skin reactions may occur in approximately one-third of patients 3
• Ensure the patch adheres properly to the skin for the entire 7-day period 5