Can a buprenorphine (opioid partial agonist) patch be used in opioid-dependent patients who are currently stable on medication?

Buprenorphine Patch Use in Opioid-Dependent Patients Stable on Medication

Buprenorphine transdermal patches should NOT be routinely used in opioid-dependent patients currently stable on other opioid medications, particularly if they are opioid-naive or recently stabilized, due to the prolonged time to reach steady-state therapeutic levels and risk of inadequate pain control or precipitated withdrawal. 1

Critical Contraindications and Warnings

Opioid-Naive Patients

• Opioid patches (including buprenorphine) are explicitly contraindicated in opioid-naive patients because they take too long to reach steady-state clinical effect and carry high morphine equivalence risk. 1
• The transdermal formulation has a delayed onset of action that makes it unsuitable for patients who have not been previously exposed to opioids or who require rapid dose titration. 1

Risk of Precipitated Withdrawal

• Buprenorphine should only be administered to patients in active opioid withdrawal as confirmed by history and physical examination using tools such as the Clinical Opiate Withdrawal Scale. 1
• Because of buprenorphine's high binding affinity and partial agonist properties, it can induce significant withdrawal symptoms if the patient is currently receiving full opioid agonists and not yet in withdrawal. 1
• Particular caution is required when transitioning from methadone to buprenorphine due to risk of severe and prolonged precipitated withdrawal. 1

When Buprenorphine Patches MAY Be Appropriate

Specific Clinical Scenarios

Buprenorphine transdermal patches can be considered as a therapeutic option in the following situations for patients with stable chronic pain (not acute opioid withdrawal): 1

• Oral administration is impossible due to uncontrolled nausea and vomiting. 1
• Risk of bowel obstruction exists. 1
• Poor digestive absorption from fistula, short or irradiated small intestine, gastrointestinal damage following surgery, or severe diarrhea. 1
• Moderate chronic renal failure (fentanyl and buprenorphine are mainly metabolized hepatically). 1
• To reduce pill burden in patients distressed by large numbers of medications. 1

For Opioid Use Disorder Patients with Chronic Pain

• For patients on sublingual buprenorphine/naloxone for opioid use disorder who develop chronic pain, consider switching to buprenorphine transdermal alone rather than adding the patch to existing therapy. 1
• The transdermal patch bypasses the 90% first-pass hepatic metabolism of sublingual formulations and may provide better analgesia. 1
• Transdermal buprenorphine has proven efficacy and may be safer than full opioid agonists, providing comparable pain relief with fewer adverse events. 1

Proper Initiation Protocol (If Appropriate)

Prerequisites Before Starting Patch

• Patient must be stabilized on sublingual/buccal buprenorphine (8-24 mg daily) for minimum 7 days before considering any transition to long-acting formulations. 2, 3
• Ensure patient is not experiencing withdrawal symptoms and is comfortable on their current dose. 2, 3
• Confirm the patient has demonstrated tolerance to buprenorphine to minimize precipitated withdrawal risk. 2, 3

Dosing Considerations

• The fentanyl patch at 25 mcg/h is an alternative option for initiating opioid treatment in patients with stable pain who do not need frequent breakthrough doses. 1
• For buprenorphine specifically, patches are approved for chronic pain management, not for opioid use disorder treatment. 1
• If maximum dose of transdermal buprenorphine is reached, consider adding or replacing with additional long-acting potent opioids such as fentanyl, morphine, or hydromorphone. 1

Managing Breakthrough Pain

Concurrent Opioid Use

• Because buprenorphine does not occupy all opioid receptors, other opioids can be given when pain is acute. 1
• High-potency opioids such as fentanyl or hydromorphone should be considered when nonpharmacologic treatments and nonopioid pharmacotherapies are ineffective. 1
• For patients on buprenorphine maintenance with inadequate analgesia, consider increasing the dosage in divided doses before adding other agents. 1, 2

Critical Pitfalls to Avoid

Surgical Considerations

• Be extremely cautious with patients who may require surgery, as buprenorphine's high binding affinity may interfere with perioperative pain management. 2, 3
• Plan ahead for surgical procedures and coordinate with anesthesia regarding buprenorphine management. 2

Drug Interactions

• Concomitant use with QT-prolonging agents is contraindicated. 2, 3
• Multiple drug-drug interactions can result in QT-interval prolongation, serotonin syndrome, paralytic ileus, reduced analgesic effect, or precipitation of withdrawal symptoms. 2, 3

Removal Risks

• Never attempt to remove transdermal buprenorphine after administration, as risks include surgical complications, infection, and damage to surrounding tissue. 2, 3

Alternative Approaches for Stable Patients

For Opioid Use Disorder

• Sublingual buprenorphine/naloxone combination tablets remain the gold standard for office-based treatment of opioid use disorder, with the 4:1 ratio decreasing diversion and abuse potential. 4, 5
• Long-acting injectable buprenorphine (Sublocade) is preferred over patches for opioid use disorder, with initial 300 mg monthly doses followed by 100 mg maintenance. 2, 3, 6
• Maintenance therapy is superior to tapering in patients with prescription opioid dependence receiving buprenorphine in primary care. 7