Guidelines for the use of Buprenorphine (BuTrans) Transdermal patch
Buprenorphine is a synthetic opioid agonist/antagonist for use in moderate to severe pain.
BuTrans transdermal patches contain buprenorphine in a continuous release formulation to be worn for seven consecutive days available in the following strengths: 5mcg/hr, 10mcg/hr and 20mcg/hr.
BuTrans patches are restricted for prescribing by the pain and palliative care teams only.
Criteria for use
Patients with chronic pain who have previously received weak opiates (eg codeine, dihydrocodeine, Tramadol) and require a topical preparation but do not yet require the level of analgesia provided by Fentanyl patches. BuTrans patches can be considered at Step 2/3 of the WHO Pain ladder. Indications for topical analgesia:
- Difficulty/ inability to swallow
- Poor absorption from the GI tract (short bowel/ inflammatory bowel disease)
- Persistent excessive side effects from oral opiates due to peaks in plasma concentrations
- Compliance problems
Contra-indications
- Known buprenorphine hypersensitivity (or hypersensitivity to any excipients of the patch).
- Myasthenia gravis
- Delirium tremens
- Pregnancy.
- Treatment of opioid dependance and narcotic withdrawal.
- Conditions in which the respiratory centre and function are severely impaired or may become so.
- Patients taking Monoamine-oxidase inhibitors or have taken them within the last 2 weeks
Cautions
- Convulsive disorders
- Head injury
- Shock
- Reduced consciousness of unknown origin
- Intracranial lesions
- Increased intracranial pressure
- Severe hepatic impairment
Dosing
Initiation
Initiate treatment with the lowest strength patch: 5mcg/hr.
Note: Patches must be worn for three days until maximal effect attained. Consider previous opioid history of the patient and continue/ prescribe concurrent po/pr analgesia during initiation.
Prescribe course of anti-emetic for first seven to ten days due to high incidence of nausea and vomiting.
Titration
After three days of treatment the dose may be increased depending on the patients response and the need for concurrent po/pr analgesia. A larger patch should replace the current patch or a combination of patches should be worn.
Maximum of two patches to be applied at any one time.
No dose adjustment required for renal impairment or elderly patients. Note: Use with caution in patients with hepatic impairment.
Counselling points
Patches should be applied to relatively hair-free, non-irritated, intact skin on upper outer arm, upper chest or upper back. Patches should be worn continuously for seven days including during bathing, showering etc. If a patch falls off a new patch should be applied. The same skin site cannot be used for three to four weeks following removal.
Avoid exposure to heat pads, heat lamps, electric blankets, saunas etc as increased absorption may occur.
Further information
Buprenorphine is only partially reversed by Naloxone. Effects of buprenorphine may continue for up to twenty-four hours after removal of patch.
