From the Guidelines
To wean a patient off opioids who is currently using Butrans (buprenorphine) patches, I recommend a gradual tapering approach using the same medication at progressively lower doses, with alternative patches including fentanyl transdermal or methadone, as supported by the most recent evidence from 1.
Tapering Approach
Start by reducing the Butrans patch strength by 5-10 mcg/hour every 2-4 weeks, depending on the patient's current dose and response. For example, if a patient is on a 20 mcg/hour patch, step down to 15 mcg/hour, then 10 mcg/hour, then 5 mcg/hour before discontinuing.
Alternative Medications
Alternative medications include oral buprenorphine/naloxone (Suboxone), which allows for more flexible dosing during tapering, as well as fentanyl transdermal patches, which have proven efficacy and may be safer than full opioid agonists in the treatment of chronic pain, as noted in 1. Methadone is also a valid alternative, but its use requires careful consideration due to its variable plasma half-life and duration of action, as discussed in 1.
Non-Opioid Adjuncts
Non-opioid adjuncts can help manage withdrawal symptoms and pain, including:
- Clonidine for autonomic symptoms (0.1-0.2 mg every 6 hours as needed)
- NSAIDs like ibuprofen (400-600 mg every 6 hours) for pain
- Gabapentin (300-600 mg three times daily) for neuropathic pain and sleep disturbances
- Hydroxyzine (25-50 mg every 6 hours as needed) can help with anxiety and sleep This approach works because buprenorphine is a partial opioid agonist with a ceiling effect on respiratory depression, making it safer than full agonists while still preventing withdrawal, as explained in 1. The gradual taper allows the brain to adjust to decreasing opioid levels, minimizing withdrawal symptoms and increasing chances of successful discontinuation.
From the Research
Alternative Patches to Butrans (Buprenorphine)
Alternative patches to Butrans (buprenorphine) for weaning a patient off opioids include:
- Methadone, as studied in 2, which found that methadone and buprenorphine/naloxone had comparable outcomes during rapid outpatient stabilisation and detoxification in low dose opiate users.
- Naltrexone, as mentioned in 3, which compared the effectiveness of sublingual buprenorphine-naloxone and extended-release injection naltrexone for opioid use disorder.
Medication Comparison
Comparing the effectiveness of these medications:
- 4 reviews the history, criteria, and mechanisms associated with opioid use disorder, and outlines the pharmacology considerations, treatment strategies, efficacy, safety, and challenges of methadone, buprenorphine, and naltrexone.
- 5 found that receipt of methadone was associated with a lower risk of treatment discontinuation compared with buprenorphine/naloxone, while the risk of mortality while receiving treatment was similar for both medications.
- 6 evaluated the distribution of buprenorphine and naltrexone initiation among individuals with opioid use disorder with vs without cooccurring substance use disorders, and found that buprenorphine treatment days were associated with decreased poisonings compared with days without medication for individuals with cooccurring substance use disorders.
Key Findings
Key findings from the studies include:
- Methadone and buprenorphine/naloxone have comparable outcomes for opioid detoxification 2.
- Naltrexone may be a suitable alternative for patients who are homeless or have certain demographic characteristics 3.
- Methadone is associated with a lower risk of treatment discontinuation compared with buprenorphine/naloxone 5.
- Buprenorphine is associated with decreased poisonings compared with days without medication for individuals with cooccurring substance use disorders 6.