How to use the Buprenorphine (Butrans) patch?

How to Use the Buprenorphine (Butrans) Transdermal Patch

Apply the buprenorphine transdermal patch to clean, dry, hairless skin on the upper outer arm, upper chest, upper back, or side of the chest, changing the patch every 7 days (or every 3-4 days for certain formulations). 1, 2

Application Site Selection and Preparation

• Choose an appropriate location: Apply to the upper outer arm, upper chest, upper back, or side of the chest where skin is intact and healthy 1
• Avoid damaged skin: Do not apply to areas with diseased, injured, irritated, or broken skin 3
• Prepare the site: Ensure the skin is clean, dry, and hairless before application 3
• Rotate application sites: Use a different location with each new patch to minimize local skin reactions 4, 5

Application Technique

• Start with the lowest effective dose: For opioid-naïve patients requiring long-acting opioid therapy, begin with 5 mcg/hour 6, 1
• Apply the patch firmly: Press the patch firmly in place with the palm of your hand for approximately 30 seconds to ensure good contact 3
• Avoid direct contact during application: Healthcare personnel should wear impermeable latex or nitrile gloves, protective glasses, and a laboratory coat when handling the patch 3
• Allow drying time: After application, allow a minimum of 30 minutes before direct contact with the application site 3

Dosing Schedule and Titration

• Standard wearing time: The patch should be worn continuously for 7 days before replacing with a new patch 2, 7
• Alternative regimens: Some formulations may be changed every 3-4 days, with comparable efficacy demonstrated for both schedules 7
• Titration approach: If pain control is inadequate, increase the buprenorphine dose in divided doses as the first step 1
• Maximum dosing: FDA guidelines recommend limiting the dose to a maximum of 20 mcg/hour due to concerns for QT prolongation 6

Managing Breakthrough Pain

• First-line approach: Use non-opioid adjuvant therapies such as NSAIDs or acetaminophen for mild-to-moderate breakthrough pain 1
• Caution with additional opioids: If short-acting opioids are needed, be aware that higher doses may be required due to buprenorphine's high binding affinity blocking other opioids from accessing receptors 1
• Consider formulation switch: If pain control remains inadequate at maximum transdermal dose, consider switching to buprenorphine buccal films or adding a long-acting potent opioid such as fentanyl, morphine, or hydromorphone 1

Important Safety Considerations

• Timing of onset: Buprenorphine provides analgesia within 1-2 hours following patch application 3
• Peak concentration: The mean time to reach peak concentration is approximately 7.33 hours (range 1-24 hours) 3
• Long half-life: The terminal half-life is approximately 64.9 hours (range 39.1-85.7 hours) due to flip-flop pharmacokinetics 3
• Bioavailability: The estimated absolute bioavailability of transdermal administration is approximately 16% 3

Common Pitfalls and How to Avoid Them

• Application site reactions: These can occur, particularly at higher patch strengths (≥10 mcg/hour), and may require patch discontinuation or rotation to buccal films 4
• Precipitated withdrawal: Do not apply buprenorphine to patients currently taking high-dose full opioid agonists without proper transition, as buprenorphine's partial agonist properties may precipitate withdrawal symptoms 6, 1
• Accidental exposure: If human skin is accidentally exposed during application, wash immediately with soap and water and contact a physician, as this could result in absorption and adverse reactions 3
• Disposal concerns: Store patches in a locked cabinet according to controlled substance requirements, and destroy unused or expired patches through a reverse distributor 3

Monitoring and Follow-Up

• Screen for mental health conditions: Evaluate all patients for depression, neurocognitive disorders, and other mental health conditions that may impact pain management 1
• Assess for tolerance: Approximately 60% of patients can manage pain with one patch alone or with one additional sublingual tablet daily during long-term treatment, indicating low incidence of tolerance development 5
• Local skin tolerability: Monitor for objective findings (mainly erythema) and subjective symptoms (mainly itching) at patch application sites 7