Buprenorphine, so misunderstood

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Endo Pharmaceuticals recently announced the availability of Belbuca, the first buccal formulation of buprenorphine FDA approved for pain. Belbuca is the first and currently the only formulation of buprenorphine that can be delivered by dissolving a film which is placed on the inner lining of the cheek carrying an indication for chronic pain. On the surface, this might look like just another one of those pharmaceutical gimmicks that puts a flashy new formulation on the market to rehash an already available medication. So what’s the big deal?

Like the old Dr. Pepper jingle goes, buprenorphine is “so misunderstood“.  But, here to clarify it for you are guest bloggers Joseph Gottwald and Dr. Jacqueline Pratt Cleary.

First, let’s start with some context. Buprenorphine didn’t get its start as a treatment for pain. Rather, it was initially thought to be helpful for reducing cravings for patients that have an opioid abuse disorder. Buprenorphine is a partial agonist at the mu-opioid receptor (responsible for opioid’s euphoric effects) and as such leads to a less robust euphoric response…voila – less abuse potential! Not long after, researchers discovered buprenorphine has some excellent analgesic qualities as well. The safety profile of buprenorphine presents an additional benefit compared to traditional full agonist opioids, as buprenorphine has a “ceiling effect.” This dramatically reduces the risk of opioid-induced respiratory depression – the common causative factor of opioid overdose-related death due to the partial agonist activity. Opioids block the carbon dioxide feedback loop that is used to stimulate the respiratory center in the brainstem to increase respiratory rate. Generally, the higher the dose, the more profound inhibition of this feedback loop. With buprenorphine, however, this effect seems to reach a plateau which is consistent with what is understood about the effects of partial agonists. Therefore, we have an opioid medication with reduced abuse and respiratory depression potential that also has analgesic properties. Given these properties, buprenorphine may serve a unique niche for patients with legitimate chronic pain requiring opioids who are otherwise not candidates for full agonists due to safety, abuse, or other concerns.   Let’s review what is currently available:

Prior to the recent release of Belbuca, several formulations of buprenorphine were already available: sublingual tablet (Subutex), transmucosal film (Suboxone), transdermal patch (Butrans), and a parenteral formulation (Buprenex).

Buprenex was released in 1985 and is intended for IV or IM administration. It is approved for the relief of moderate to severe pain is typically reserved for use in the inpatient setting.

Subutex is a sublingual tablet containing buprenorphine that is approved for the treatment of opioid dependence. Although this formulation has been successfully used off-label for the treatment of chronic pain, it is important to note that the manufacturer recommends against the use of Subutex for pain due to reports of death in opioid-naïve patients after receiving 2mg sublingual tablets. Some other challenges with this formulation are concerns for intolerance (many reports of nausea) as well as variable bioavailability.

Suboxone is a transmucosal film product intended to be dissolved under the tongue that combines buprenorphine and naloxone in one formulation. Like Subutex, Suboxone is only approved for the treatment of opioid dependence. The formulation of buprenorphine with naloxone carries some clinical controversy. The initial rationale was this combination included naloxone to act as an abuse deterrent.  If the product was to be crushed, injected, or snorted the theory was that the naloxone would antagonize the opioids effects.  However, this theory has several flaws. First, buprenorphine has a much higher binding affinity for the mu-opioid receptor than naloxone. Secondly, not only is buprenorphine more strongly bound to its activity site, it has a longer elimination half-life than naloxone. Buprenorphine is not only binding stronger, it is hanging around its site of activity longer.  So the presence or absence of naloxone here would in general provide the same result.

Fast forward to the new release of Belbuca.  Both Butrans and Belbuca have FDA approval for the management of “pain requiring around-the-clock, long-term opioid treatment not adequately controlled with alternatives,” the new standard labeling required on all extended-release opioids indicated for chronic pain. Additionally, both allow for short-acting full agonist opioids during titration periods.

Butrans, a buprenorphine transdermal patch product, is available in dosages ranging from 5mcg/hr to 20mcg/hr. According to the manufacturer, this range could provide adequate analgesia for patients requiring up to 80mg oral morphine equivalent daily dose (MEDD) prior to initiation. Each patch is intended to remain in place for 7 days and takes ~3 days to achieve steady state levels. Currently, the maximum approved dose is limited to 20mcg/hr due to concerns of QT prolongation. This recommendation is based on the study cited in the prescribing information that states the 10mcg/hr dose resulted in no clinically meaningful effect on mean QTcF whereas a 40mcg/hr dose resulted in a maximum mean QTcF prolongation of 9.2ms across the study period. We’ll return to the concept of QT prolongation with buprenorphine shortly.

Belbuca, the newest buccal film formulation of buprenorphine, is available in dosages ranging from 75mcg to 900mcg. The film is intended to be utilized every 12 hours and according to the manufacturer may provide adequate analgesia for patients requiring up to 160mg MEDD prior to initiation. This is a much needed dosage expansion as there are many patients with significant indications for opioid pain who are not candidates for full agonist opioids due to concerns for either abuse or adverse events. Buprenorphine may be a viable alternative if we can provide a dose with adequate analgesia. Again, the dose is limited to 900mcg every 12 hours due to concerns for QT prolongation – doses in the approved range resulted in QTcF values between 450-480ms for 2% of patients.

There is a good deal of discussion regarding QT prolongation here and for good reason – it has the potential to cause serious harm. However, it is also important to place the magnitude of prolongation in the context of other available and widely used drugs that also are known to cause QT prolongation. You can find the details on this data in the linked article below, but here is a figure that provides a comparison of QT prolongation magnitude among a variety of drugs including antipsychotics, antidepressants, antibiotics and buprenorphine. Note that this data is not meant to be used for direct comparisons between the various agents due to differences in study design, QT correction strategies and population variations, but is provided as context for the current landscape of QT prolonging drugs.  It is important for pharmacists and providers to recognize that drug-drug interactions, history of cardiac conditions, as well as concomitant use of medications which prolong the QT interval should all be considered during therapy selection.

The introduction of Belbuca allows for on-label use of higher buprenorphine doses but also highlights the need for providers to become familiar with dosage conversion, acute pain management options for patients on chronic buprenorphine therapy, and abuse potential.  We didn’t get into the discussion much, but acute pain management in the perioperative setting for those on buprenorphine is discussed more extensively in an article by Fudin et al HERE. Basically, acute pain management becomes much more complicated when you’ve taken up all the available opioid receptors with buprenorphine. Buprenorphine’s unique pharmacology may provide an option for complex pain patients with a history of opioid misuse/abuse, or for those that have any number of comorbid medical risks. The warning for QT prolongation has unfortunately put a limit on several of the dosage forms; however, the provided information and forthcoming studies will hopefully shed some light on this highly debated topic. Each patient should be approached as an individual case and warrants a discussion regarding clinically relevant QT prolongation.  Buprenorphine is a much needed compound that pain practitioners should be grateful to have in their armamentarium; however, knowledge and understanding of its properties is a necessity.  Now with the release of the new Belbuca products the “ceiling” was raised a little higher.

You can find a detailed version of this article in the Pharmacy Times HERE including references for the above information.

Please comment!

About the guest bloggers:

Gottwald_Joseph
Joseph Gottwald is a 2016 PharmD candidate at the Albany College of Pharmacy and Health Sciences and will begin medical school after graduation. He has experience as a research assistant in organic synthesis and interest in neuropharmacology. He is currently under the mentorship of Dr. Fudin subsequent to completion of an advanced practice rotation in pain management.

 

 

Jacqueline pratt clearyDr. Pratt Cleary is a PGY2 Pain and Palliative Care Resident at the Stratton VA Medical Center in Albany, New York, under the mentorship of Dr. Jeffrey Fudin. Her research interests include risk stratification prior to and following opioid therapy with emphasis on requisite naloxone qualification for in-home use. She has been a leader in the expansion of the risk index for overdose or serious opioid induced respiratory depression (RIOSORD) tool presenting and educating providers and patients on a national scale. Prior to completion of a PGY1 General Practice Residency at Sentara Healthcare System in Norfolk, Virginia, she earned her BS in Biochemistry at Furman University and her Doctor of Pharmacy at South Carolina College of Pharmacy, MUSC Campus. Dr. Pratt hopes to pursue a career in pharmacy academia upon completion of her PGY2 residency training.

 

530 thoughts on “Buprenorphine, so misunderstood

  1. Amazed to find this material. I can’t manage to work my way through the 520 comments, maybe my thoughts / concerns / questions have already been addressed. Background: A heavy metal compound, platinum to be exact, took my life away from me in 2010. The heavy metal poisoning came by way of well intended doctors / oncologists infusing Oxaliplatin into my veins during chemo. My first middle and last names at this point are all PAIN. For years I did “Ok” with 5 mg Roxicodone and slightly better with 2 mg hydromorphone. This year because of the “opioid crises”, my apparent increased consumption beyond my authorized limit (which I did not even know I had been doing in both 2017 and 2018) and a wholly defective palliative care specialist – the rug was pulled out from under me and I have been denied effective pain mitigation since May. After working through all the bogus methodologies / meds to try to get me some relief, the new pain management specialist is now ready to have me experiment with Belbuca. We were going to go with the buccal adminisrtation route but that has been rejected by my insurer. The transdermal patch route is okay with them but somewhat risky for me as I rash up easily to most adhesives.

    I was always concerned about raising the oxycodone dosage (it has large step sizes) and thence running out of room should some other disaster befall me leaving no room to treat without the attendant risks of death from respiratory suppression. It sounds like buprenorphine carries similar risk and may actually make it difficult to treat me with any opioids in the hospital if needed. (BTW I will never let the stupid fools put morphine in me again! – bad bad withdrawls even when transitioned to 10 mg percocet.)

    1. Pain Pain Pain, Buprenorphine, unlike traditional opiates has a plateau effect on its ability to cause CO2 accumulation, so it is far safer than traditional opioids. if the patch is a problem in terms of a rash, ask your doctor to prescribe triamcinolone topical spray (not the one used for asthma), and use the spray 1-2 sprays prior to placing the patch over it.

      1. I am allergic to triamcinolone. The pain doctor prescribed a Betamethasone Valerate 0.1%cream as a prep. I put the first patch on yesterday. With my skin the generic patch from Teva just wouldn’t stick. Lots of paper tape to keep it down. Hope the transfer / absorption goes smoothly – not peaky. Issues with hydrocortisone absorption has shown itself to be an issue for me (blood pressure) so I know the stuff should go in. Fingers crossed. In roughly five days I am ordered to supplement the Butrans with Lamotragine 25 mg once daily. Reason for the delay is to help sort things out if I have intolerable side effects from one or the other med.

        Any suggestions on how to get the Butrans economically. It’s really pricey here even with my insurers blessing to treat me with it.

        1. Pain pain pain, You may have had an adverse effect to triamcinolone, but it is doubtful that you are allergic. It’s possible that you had a reaction to triamcinolone previously in a cream or ointment formulation and that you were allergic to the vehicle rather than the drug itself. It is not practical to put cream on the skin prior to patch placement. A better alternative option might be Clobetasol topical, just one spray. It is aerosolized as is Kenalog Spray (Triamcinolone Acetonide Topical Aerosol.

  2. Dr. Fundin,
    I am a CPP for the last 2 decades. I am a hypermetabolizer of Morphine and have tried all sorts of meds to help with the pain from hEDS and a Chiari 1 Malformation. I ended up back on MsContin 15mg 3×daily and 15mg MsIR 3×daily to keep round the clock pain control. My Chiari symptoms are increasing which has led to another change. I am now on Belbuca 300mcg 2×daily and Hydrocodone 10/325mg 4×daily. My issue is this…I already have SEVERE headaches from the Chiari. I tried Buprenorphine 8mg tablets 3×daily for 2 months a year ago. It caused headaches (a different kind than the Chiari headaches) and it caused agitation/irritability and RAGE. Not just a little bit, either. I have a college-aged daughter, and she said something to upset me and I punched her in the face. I never even spanked my children growing up, so you hopefully can understand why this is so out of character for me! I went off of the buprenorphine tablets at my next appointment. Now due to the clinic not wanting to prescribe the big 3 (Oxymorphone, Hydromorphone, and Fentanyl) but with all of the other med failures, she decided to try Belbuca because it it in mcgs instead of Mgs. She swore it would be different. Now I have been on it for 3 days. I feel the headache come on 30 minutes after it has dissolved and now I am already feeling the rage again, only this time directed at my husband. I kicked him in the head. I am not making excuses, it is as though I have no control over myself. I start to get irritated then just BOOM out of nowhere. My doctor said that it can’t be from the Belbuca. But I don’t normally walk around hitting/kicking people ESPECIALLY those that I love. Is this rage IMPOSSIBLE to feel because it is in micrograms? I haven’t had the urge to hit someone since the last time I was on buprenorphine and now it feels the same as it did then. Have you ever heard of this?

    1. Trena,

      If you were on opioids at the time(s) you took the buprenorphine and had mood changes, then the most likely explanation is that buprenorphine caused opioid withdrawal. The lower the buprenorphine dose, the less likely or less severe that would happen. If you were not on opioids at the time of buprenorphine, it would be unlikely to see such mood changes, but it is possible due to the complex pharmacology and genetic variability of opioid receptor makeup within the central nervous system.

  3. I started taking belbuca 300 mcg and for the first 2 days I had great pain relief but now on the 3rd day I ask no longer getting the same relief. I was also getting a calming relaxed feeling from it but I’m also not getting that either.

  4. I developed tolerance to morphine 90 mm and my doctor switched me to Belbuca. He started me on 300 mcg but it doesn’t seem to be cutting the pain yet. Can you please tell me what Belbuca dose would be equal to the morphine dose I was on?

    Also – I was prescribed quick acting morphine for breakthrough pain but now as I understand it, that won’t do anything correct? So what should my doctor prescribe me instead that is compatible with Belbuca? Thanks for any advice.

  5. Hello,

    My doctor recently switched me from oxycodone and Oxycontin to Suboxone for pain control for Ehlers Danlos, post multiple cervical surgery pain and DDF. Zero abuse history. Suboxone instead of Belbuca due to high doses I was on. I’m currently on 4mg but could easily taper to 2mg.

    I have zero pain control. I’m miserable. I wish I could say I did but I just don’t. My doctor keeps saying I’m comparing apples to oranges (with my previous meds) and I realize Suboxone is different, but it’s just not covering my pain at all. Do you think that a combination of Belbuca and a full antagonist for breakthrough might be worth a discussion?

  6. Hi please help! I’ve been trying to figure out the mme for what I take. I am
    prescribed belbuca 300 2 x a day and 3 5mg hydrocodone a day. My doctor is concerned about going up because of the cdc guidelines. Since they don’t consider buprenorphine to be a threat for overdose for use in opioid use disorder they don’t have a conversion for it but what if you aren’t taking it for OUD and it’s for chronic pain? Then how do we know if I am being prescribed too much for the 50-90mme? Should she only be concerned about the full agnostic opioids she prescribes and their mme? Or should she be adding the two together somehow?

    1. Tonya, They are all buprenorphine. belbuca is a lower dose but specifically FDA approved and indicated for pain. The other two are FDA approved for opioid use disorder. If the lower dose of Belbuca is effective, that should be the choice medication. Also, you may be less likely to be judged as having an addiction problem with belbuca because it is indicated for pain, not opioid use disorder.

    2. Hello , I am so glad I found this blog – you are giving us great information ,thank you! I hoped you could reply to my question. I had surgery of herrington rod placement for scoliosis when I was 11 years old , over 44 years ago now! The older I get , the worse the pain. I have spinal stenosis and deteriation of the spine now too and add Lyme Disease undiagnosed for 2 years .For 3 1/2 years I have been taking Oxycodone with tylenol 10/325 3 x a day & oxycontin 20mg time release 2 x a day and have been able to continue working .My doctor just took me off of the Oxycontin and put me on 75 Belbucca 2 x a day. He said it would work better since I complained it wasnt working that great this month due to a car accident I was in. It is now day 4 and I have no relief at all from the Belbucca and have not been able to go to workfor 4 days! I feel so much pain , and what I believe are withdrawls and its a nightmare! The dr refused to change it back and said keep trying . Is it the wrong dose? Even the oxycodone with tylenol seems to have lost its effect. I cant even drive. Any info would be appreciated .Thanks

  7. I have chronic back pain which my family doctor was prescribing me 10mg of Norco and I was taking approximately 8 per day for a year. I recently switched to a pain management doctor who has prescribed me 450 mcg Belbuca films. The film works but typically only lasts for 8 hours. The directions on the package and my doctor have told me to take them every 12 hours. Have you had other patients exhibit the same result as mine? The medicine works but only lasts 8 hours. Can I take them every 8 hours instead of every 12?

      1. I had a gerd surgery, and after taking it for pain relief for Sarcoidosis I feel like battery acid has been poured down my throat and into my stomach. I cannot swallow pills or food without feeling like I might choke to death. I have asthma again with chest pain. Everything burns. I am trying to stay above 90 lbs, but it is very hard. I haven’t felt this bad since before my surgery. And I take 40 mg of nexium 2x daily, tums etc. Worst medication ever. Plus It causes severe migraines that topamax, botox, and imatrex won’t even touch! Horrible!

        1. Buprenorphine is an odd drug. The manufacturer of the patch version, which is indicated “for pain” can’t explain why the Route of Administration and lower doses make it better for analgesia. The pharmaocokinetic profile shows blood levels with weekly dosing of the 10mcg/hr patch running from 80 mircograms/ml at lowest (day 7) to 194 micrograms/ml at day 2. Its looks like rolling hills-so much for ‘steady state’ What most dont realize is using bupe for pain is not recommended if your daily mmm requirement is above 80mg. Most pain patients can tolerante 3-5 times that amount. Just my two cents!

  8. Any information regarding converting among buprenorphine products? (Especially for an institution’s formulary). Ie: Belbuca to Subutex?

      1. I was diagnosed with spinal stenosis at age 34. Had my 1st surgery at 35 was multiple fusions and halo brace for 3 months. Stretched in bed and 2nd surgery with another. 3rd surgery same only had nerve problem in hand after. 4th fused 2 in lower back. 5th T1 removed and replaced with titanium plate and screws. More nerve problems this time down shoulder and arm into hand (excruciating) 6th spinal cord stimulator to help with nerve pain because they don’t want to fuse last spot just above T1 only last resort. I have fibromyalgia, bursitis in my pelvis on left side. 2 bad knees left is bad getting cortisone shots in it. Pain deep in shoulder socket, extremely painful, getting cortisone shot in it. Joints are all bad, hands full of arthritis along with it being in most of my body. Had arthritic bone cut off my foot and 1st toe cut shorter to keep from happening again.
        I have been on pain meds since late 80s. Vicodin, stadol nose spray, fentanyl, soma, flexaril, gabopentin, lyraca, celebrex, and so many I have forgotten. So many antidepressants my Dr. is stumped as to what else to try. Cymbalta, Lexipro, Zoloft, Paxil, Prozac which worked the best. However, after having my daughter i could no longer take it because I broke out in a rash. I asked my Dr to lower my meds wanting to get off them I managed to knock myself down to currant meds. Currently was on MS Contin 15mg every 12 hrs., 7.5 mg Norco 2x day, 200 mg Lyraca 2x day, 10 mg Baclafin 3x day. Dr just put me on Belbuca 150 mg twice a day. I can breath better, urinate better, neck pain better, head more clear except morning headache and swollen feet and hands and swollen left arm and leg to go with the feet and hands.. My knees, nerve pain, arthritis and bursitis still hurts badly. With the moriphine I forgot I had bursitis and seemed to help better with pain. I was still hurting on moriphine but am so tired of the meds. Tired of pain, especially nerve pain. If Dr. raises Belbuca to 300 2x day will this help with nerve pain. If not what would you recommend? Thank you for what you are doing on this website it is very helpful and educational. You are kind to take your time to read and respond to all these emails. Pain sucks the life from me daily and has stripped me from a normal life. I pray Belbuca is the answer.

          1. Nucynta worked great for me. Fewer side effects than all other opiates. Only problem was it made me itch. No rash though. I have now been switched to this film which is giving me a slamming headache and very drowsy. Only 2 days in so I hope it will subside

        1. Hi my pain mgmt dr put me on butrans patch that puts out 10mcg/per hr that I wear and change out every 7 days with oxycodone one 3 times a day for breakthrough pain and it works wonderful. I have many of same problems you do 3 spinal surgeries on 7 levels, hip replacement, knees need surgery, have spinal stenosis and did and scoliosis so….basically we are falling apart lol…but the butrans patches work wonders and you don’t feel drugged up all the time even with meds for breakthrough pain. It is the same med as you are taking in strips but it is in form of transdermal patch.

  9. I have successfully transitioned from 90mg morphine a day to 900mcg Belbuca.I would say general pain reduction is similar with less side effects. Exactly as you said. Especially with the constipation. I do continue to have breakthrough pain 3 days a week or so. I used to take morphine 15mg IR for that. Is there anything I can take now that I’m on Belbuca for breakthrough pain?

    1. Jim, Speak with your doctor, but yes, you can use non opioids alternative for breakthrough pain if there are no medical contraindications. Sometimes certain opioids can be useful too, but the higher the belbuca dose, the less effective standard opioids will be.

    1. Frank, I never said that! Higher doses of buprenorphine in various products is in fact FDA approved for opioid use disorder. Buprenex, Belbuca, and Butrans are all specifically FDA approved as analgesics, NOT OUD.

  10. I have been on Belbuca 450mcg films for 4 months now, how ever when I do my urin drug test for my pain management the Belbuca does not show up, I was wondering if something like my water pills or any meds realy could cause the belbuca not to be present in my urin? Ive asked the dr, (even offered on the spot testing) my pharmacy, and tried looking it up on the net, but no one can give me an answer. Has anyone ever had this happen to them? The Dr kinda acted like i was lieing.

    1. Sara, The cut-off detections in urine for buprenorphine are too high to detect Belbuca. If you were positive, you doctor should be concerned that maybe you were taking more than prescribed. if he/she s concerned, they can do a buprenorphine finger stick test that is manucatured by Fristox. they have the lowest cut-off.

    2. I just went to my dr. today for my PM program and have been taking belbuca 450 every twelve hrs. for about 3-3 1/2 months. I t has been showing up in my urine test but was told today last month it did not show up at all. I take exactly as prescribed not missing any doses or doubling or taking more closely than prescribed. I don’t understand why it didn’t show up. Only thing different is now that weather is getting hotter I drink fluids a lot more often. I sweat heavily and urinate more now with increased fluids. Aldo i take 2 mg. of lorazepam daily and every couple of months it doesn’t show up. I take my meds correctly so am very confused. Years ago I took 7,5 mg 2 times daily and one 10 mg daily loracet for over 5 years and was urine tested where I work about 4 times yearly and never had a positive drug test then. Could my body metabolize the meds more quickly than others and how can i know? Thank you for responding.

      1. Buprenorphine often does not show up at that does. If your doctor is squeamish about that, he/she can order a blood level using Firstox, as their cut-off for detection is low and it’s a simple fingerstick test.

  11. My husband suffers from chronic pancreatitis. He and his dr recently made the decision to change from a 25mg Fentanyl patch to 300mcg Belbuca twice a day. We both know that he is going to have to adjust the dosage to get the correct one but he asked the dr about taking the Belbuca 3 times a day instead of twice to avoid doubling the dosage. I was not with him at this appt and he cannot remember the explanation the dr gave as to why this would not be effective. Can you?

    1. Belbuca can be prescribed off-label every 8-hours, although the insurance company may refuse payment since it is askew from the labeling. But, the statement about effectiveness or lack thereof is untrue.

  12. I made the switch from 90MG morphine to Belbuca. Doctor has me fairly quickly moving to 900mcg/ day. Starting to feel pain relieving effects and beginning to feel pretty good. I know the conversion from morphine to Belbuca is difficult to compare, but what do you think of this as the final dosage vs. what i was on with morphine. I just want to make sure i’m getting the relief i should get without taking too much or not enough. Also, how long would it take for things like urinary retention and reduced testosterone levels take to improve. Thanks.

  13. I have been on butrans 10mcg since my 3rd back surgery in 2012. Works extremely well.
    However, I accidentally threw out one month’s supply. Although, the Dr wrote me an interim RX, insurance would not cover it (as it was off cycle) and it was too expensive. I decided to tough it out until the following month.
    However, I became very confused, acting out of sorts.
    Could this be related to the month without the butrans or..also, my husband and pet died recently.
    Everything is fine now (I never did suffer withdrwal, just extreme pain). To what should I attribute the temporary mental instability.
    Thank you

      1. I currently take 2mg suboxone sublingul twice a day and my tongue and gums are becomming extremely sensitive. I have SYRINGOMYELIA and this medication works wonders. Is it the naloxone that causes irritation? Would i benifit from a transdermal patch or the new form of subaxone? What about the tablets? Will the medication not work if i injest it?

        1. Transdermal is a possibility, but the highest dose is far lower than what you are taking. The injectable long lasting buprenorphine products might be a good option if your insurance will pay for it.

      2. I was on 8mg suboxone and now given 150mcg belbuca. I would only take half of my 8mg. Should I be taking 2 belbuca to get same effect? Dr said start with 150mcg but do 2 if doesnt help. What is the dosage difference

  14. I moved from the UK and spent a decade (ish) on Buprenorphine 70mcg/Ph after all other medications and other doses had failed to give the same consistency and relief. I ran out of patches on Wednesday May 8th. I’ve had no withdrawal symptoms, no addiction so no need to dose myself on the various opiods I have been prescribed ranging from morphine to tramadol. I have needed to use the Buprenorphine sublingual 400mcg I have from the UK but for the pain as required not maxing the dose as an addiction driven need.
    I know not everyone is the same but certainly I’m a case that proves the truth in your article. Now I’m going to reread the article as I battle the insurance company to get the safer medication over the morphine they agreed to. Thank you.

  15. Do you recommend patients who are on buprenorphine wear ID bracelet or other info to let emergency crews know that they will NOT respond to Morphine or other pain medications as expected?

    1. Tasha, That is a great idea! It would need to delineate though if the bupe is for opioid use disorder or for pain, because that could make a difference in the treatment.

  16. I actually have a question not a reply.
    I have been on buprenorphine 8mg a day for 4 years. The entire time I had blue cross blue shield insurance however I have lost my job and now have to pay out of pocket for both the Dr visit and medication. My fiance is prescribed belbuca 600 mcg and I’m wondering if it would help me until I can financially afford to see my regular doctor.

    1. The Belbuca dose is too low, and using someone else’s controlled substance is dangerous and also a felony if caught.

  17. I was on opioids for chronic pain and got changed to Belbuca 150mcg 2 times a day by pain specialist. I lost follow up with my pain practice and PCP is managing it now. PCP wants it to be changed to Nucynta 50mg twice and taper. Should I stop Belbuca and start Nucynta right away or slowly taper Belbuca down and then start? Is the Nucynta dose appropriate?

      1. My husband is on a 10mg Bup patch for his back injury. I am healthy and not on anything. Will him being on the patch lower our chances of conceiving? We are trying to get pregnant with our first child.

      2. Hope you can answer mine…I have 24 cavities in my 24 toothed mouth….six months ago, I had no cavities,,,,anyway, I have to get some serious work done, (implants)….my Doc prescribed pain meds for a week…(and held me off my subutex fpr that week,,, will I withdrawal from my subutex? …this is my first morning on pain meds,,,and I’m wondering if he should have prescribed me a half sub a day? I am wondering before I call and waste his busy time ….I feel ok so far, but my oral surgery is tomorrow morning and I darn sure dont want to have withdrawal symptoms the day of my scheduled surgery…please let me know if I should call my Doc,,,or not worry….Thank you so very much (maybe. You’ll be able to see and respond before my surgery, sorry, for short notice,,,,it was short notice for me as well)…..Carrie

        1. Carrie, Even though you stopped your Suboxone, it will stay around for a few days. I cannot give medical advice here. I do encourage you to keep in close contact with your doctor and make sure you have an emergency number to call, and ask that a plan be put in place for off hours in case you have any issues, because most clinicians do not have the expertise to deal with this, especially during off hours.

          1. I really have a question?Im on 10mg hydrocones.i have severe chronic pain. I have raised and osteoarthritis. 5 surgeries on my for carparpal tunnel, 3 screws in my tail bone and 3on my toes.. I urt Co bad and don’t want to be on pain pill anymore. Would belbucca be good for me and should I ask my Dr. About it…

  18. Hello Dr.Fudin, im taking 60 morphine and 275? Norco, and my P.M.Dr. wants to try Belbuca on me. I have RSD, which has taken over most of my body. i have been in pain last 9 years. What dosage of Belbuca is considered equivalent to what I take now? Without getting the withdrawal symptoms, cause I already have nausia and like daily. My RSD, has taken control of mist my body including inner organs. My dr.doesn’t believe RSD can mess with your inner organs. Most of my drs. Don’t even know what rsd, is. Even at the hosp. They ask what is it. Is there a site for Belbuca that has lower cost rates that you can think of? How much difference is is compared to what I take now? I understand the generic brand. Is this Belbuca something that may work, after my meds seems to hit its platue? How does it work in your bloodstream by using the film in your mouth? Thanks to you. Help gratefully needed.

    1. Cathy, there is no such thing as Norco 275. Notwithstanding, I cannot give medical advice on this forum. If you or your doctor which for me to do a comprehensive chart review with recommendations, our Pharmacotherapy Team can review your record and provide that service.

  19. Hello Dr.
    I am currently taking hydrocodone 10/325 up to 4 times per day for OA and fibromyalgia. During my last visit the nurse practitioner gave me prescriptions for belbuca 150mcg every 12 hours as well as my usual hydrocodone 10. She said take belbuca twice a day and use the others for break through pain. I’m confused because I thought belbuca is for helping with withdrawal symptoms. I admit I have not taken a belbuca yet as I don’t know what to expect. Any info would be helpful. Thanks.

    1. Buprenorphine is FDA approved for pain, not withdrawal symptoms and not opioid use disorder. Buprenorphine comes in may dosage forms; some are indictated for pain and some are not, but they all work for pain.

      1. I hope I’m asking this question in the right spot. I have a question regarding belbuca and hydrocodone. I’m currently prescribed Belbuca 300mcg twice daily off label for chronic pain and 3 x 5mg hydrocodone a day for breakthrough pain. Before the 2016 CDC guidelines came out I was taking 3 x’s a day 10 mg Percocet with the belbuca. My genetic drug metabolism testing I had done said that hydrocodone for me would not be as effective as Percocet would be since I take Paxil as well so it made sense I took the Percocet with the belbuca not hydrocodone. My PCP is nervous about going back to the 10mg X 3 a day Percocet with my belbuca (which worked before) because of the MME being too high. We cannot find any information as to how this would convert and if this is considered too high of a dose for the CDC to be ‘happy’ with. Could you tell me what my current MME is and if I was to have the Percocet would it be considered too high for the guidelines. I don’t want her to get in trouble but my pain is not being managed like it used to be and she would like to help me if we could understand how it converts and if it’s considered safe.

        1. Jennifer, there are a number of ways to approach this. First, there is no accurate morphine equivalent of buprenorphine. Second, Belbuca is not being used “off-label”; it is FDA approved for pain, not opioid use disorder. If you are on paxil, it has a more profound affect on oxycodone metabolism, not hydrocodone. Paxil inhibits CYP2D6, an enzyme that is responsible for converting 2% of hydrocodone to the more potent hydromorphone, and also for converting 12% of oxycodone to the more potent oxymorphone. The amount of Paxil that will affect hydrocodone is comparatively negligible. One approach is to change Paxil to a different SSRI – that doesn’t affect CYP2D6; one example is fluvoxamine. But since you have pain, an SNRI would be a better choice because it could treat pain and depression – an example is duloxetine. 7.5mg of oxycodone is about equivalent to 10mg of hydrocodone.

          1. Anyone I’ve encountered including my dear self has had serious issues with duloxetine (aka Cybalta). Don’t do it! Potentially far worse is off-label use of Lyrica (pregabalin). Off label use of that should be outright outlawed in my book.

      2. Dr Fudin
        I have been tapering down from very high dose opioid therapy for chronic CPRS pain. I self tapers off of 150mcg fentanyl patches every 2 days along with 100 mg hydrocodone and 108mg dilaudid daily. I am down to 32mg of dilaudid daily. I have endured a very difficult taper with a truly wonderful pain mgmt team. Due increased pain, my Dr added a 10 mcg buprenophrine patch. Is this common? To date I endured a bit of withdrawal when I added the patch. The withdrawal feelings have diminished and my pain is better controlled. This combo may well allow me to start tapering the dilaudid again. Is it feasible to increase the buprenophrine as I reduce the dilaudid yo help control pain to a greater degree? Thanks! C

          1. Dr Fudin, Perhaps I was not as clear as I could have been. I no longer use any Fentanyl or hydrocodone. I self tapered off of the Fentanyl and hydrocodone. I now use “only” 24 mg of hydromormorphone daily. Still a lot I know, but still tapering that down, hopefully to 0. The 150mcg twice daily of Belbuca has provided me tremendous pain relief, my life is better now than in the prior 15 years. Hope this response is a bit more clear. I appreciate your feedback.

      3. Some versions are and thats why you confuse well meaning patients. Reckitt Benkiser told me verbatim “not pain medicine.’ I got zero pain relief from a trial of Suboxone (off label ‘for pain’…what a joke). I think you are in bed with Andy Kolodny….

    2. Of late, these drugs have been prescribed to deal with addiction. Fact of the matter is that it works great for pain. I have been taking subutex for 5 months with much better results than oxycodone. I have no cravings or desire to take more. I’m now using the Bu trans patch. All of these drugs are habit forming, but IMO the belbucca or Bu-trans etc. is better for long term pain management than opioids. If you are a long term pain patient, I would try to switch from opioids like hydrocodone or oxycodone. IMO they influenced me to keep taking more as my tolerance increased. I have been taking pain meds for over 9 years now.

  20. Great job for the helpful info. I was on 60mg oxy x6 a day then went to 150 bupren. then titratrated for 3 weeks to 300mcg. belbuca. Still getting some withdrawl issues. But much better than before. Have issues when first start taking the belbuca, takes awhile to kick in versus the oxy immediatevrelease? Please keep up the great work, you are very helpful.

      1. More likely than not, you are experiencing serotonin withdrawal, not opioid withdrawal. Discuss this with your doctor. It can be treated with an SSRI and slow taper.

        1. Hi there… I’ve been tapering my pain medication and saw about serotonin withdrawal. I have had a feeling that I may have experienced maybe some serotonin syndrome when my old pm dr had me taking opana ER 10mg 2x daily plus norco 10/325 3x daily along with Xanax 1mg as needed and soma or robaxin. I had to stop the cymbalta due to becoming worse. I had to go to urgent care. I was feeling weak and just not myself. Increased depression, a lot of crying, the list goes on. I had also lost my mother and our family dog and a very good friend that year. I have not felt the same since. Very depressed, hopelessness, fatigued, pain seems to have gotten worse as well. I have double scoliosis, DDD, herniated discs, spinal stenosis, coccyxdenia, and arthritis in my back. I also have torn cartilage in both knees. I saw an info pamphlet about Belbuca today at my pm dr. I currently am prescribed 20mg opana ER 2xdaily and 5 10mg norco for breakthrough. Wondering what would be the equivalent to that with the Belbuca and if it would be something worth considering? Starting to feel some side effects from taking a lot of tablets a day. I appreciate all of the info and help you are providing! Thank you!

          1. Oh, I also forgot to mention I have sciatica as well. I do get cortisone injections, facet injection, and rhysotomies (however it’s spelled). I’ve had so many cortisone injections in the last 10 years I’ve lost count and am having some weird side effects from that too now, such as agitation, or what I would kind of explain as “roid rage”. Seems to last a few days to a week then subsides but I also notice other issues. Anyway, sorry for the long winded reply. It’s an odd coincidence I came upon this website after seeing the pamphlet for Belbuca today and also very recently seeing it when researching about other medications to manage my pain.

          2. Belbuca is a viable option for you and much safer than Opana considering the combination or drugs you are on. Determining an equivalent for Belbuca is difficult and very patient dependent. My suggestion is that you work with your doctor and taper your current opioids when introducing Belbuca. It shouldn’t be done all at once.

          3. Eli Star,
            My pain management doctor recently decided to step away from the pain management as the overwhelming amount of red tape and the opioid crises increased. I seen the writing on the wall and started tapering off the the prescribed Opana ER 30 mg twice a day a hydroconde 10/325 up to 6 a day. It was not easy and took me almost two months to get off the Opana. I am so glad the Lord gave me the strength to get passed it! The Opana was making my pain worse and constantly made my feet feel frozen litterally! I am in a lot of pain at times but I would rather be in pain than not feel anything at all (it was very depressing). I will never take anything with moriphine in it again I had no idea what it was doing to me. I have so much clarity now colors are vivid and I can actually remember things now. I hope this encourages you to find an alternative pain control as I am still working thru my own. Much love and best wishes!

  21. I was taking 60mg Morphine and 40mg Oxy for breakthrough plus getting regular RF, steroid and trigger point injections as well as nerve blocks in different areas as indicated. I do gain some relief from the injections, especially the RF Injections, but that only covers a portion of my pain issues. The pain medications had all but stopped working. I’ve truly never felt ‘high’ from the meds past the first few days a bit of drowsiness. I had zero functionality and was only asking for simple function, a simple life with simple pleasures. I’m diagnosed with Lupus, RA, Arthritis, Sjogrens, Fibromyalgia, Migraines, IST, Gastroparesia, Spondylitis – I have very little collagen left in my joints so my right hip is bone on bone as is my left shoulder and neck. My exhaustion is extreme as is the pain and sleep evades me even with sleep aids and a well organized sleep environment. My Pain Mgmt Team and other Specialists have been vigilant and professional in treating me as an adult and with respect since age 24 upon Lupus/Mixed Connective Tissue Disease dx. I’m 48 now and worked and raised a family successfully until 7 years ago when I had to go on Social Security Disability. I was approved in 6 months with no hearing thanks to my doctor’s diligence. I resisted pain medication most of my life knowing I was likely in for a long road. I started taking hydrocodone 7 years ago, Pain Mgmt switched me to morphine about 3 years ago, added Oxy a year and a half ago when my hip got so bad I couldn’t stand, walk, sit or lay on it. Upon the complete failure of these medications, they suggested Belbuca on the 1st of April this year. After 7 days, they titrated me to 300mcg every 12 hours. It’s like a miracle! That hip that I could barely walk on? I can walk fine now and roll over in bed and sit and even gently exercise it without pain – I can sit with my legs crossed!! I do still have significant neck pain and have RF injections scheduled to address that, as well as PT (which hasn’t been successful in the past), but it isn’t anything like the 10 rating from before – I’d give it a 5-7 depending on time of day and what I’m doing ( key word: ‘Doing’ I’m actually ‘Doing’ things now Wow). The first 8 days, my migraines increased in severity and my nausea was still bad, but understand that for the four months prior, and at other times in my life, I had been in such bad shape that I could barely get out of bed. Just to grab food or water or go to the bathroom seemed an insurmountable task. The month prior, I was vomiting and passing out from pain and weakness and I lost 14 pounds – that is a Lot of weight! Fast forward twenty seven days – I’ve gained 3.6 pounds, I’ve slept ALL night long for 12 days in a row, I’ve been cooking my meals, doing laundry, showering, visiting neighbors, doing light cleaning and having to remind myself to Pace myself! A part of me is fearful that the effects of the Belbuca will wear off and the miracle is temporary. I can’t help but worry, regardless I’m going to enjoy every last second of it! I’m extremely grateful though that my doctor’s are able to see the person behind the pain and didn’t give up. They saw the happy lady that I am and cared enough to give me back a piece of myself. When they saw me for progress on Monday, dressed in regular clothes, with make up and a big smile on – 3.6 pounds heavier the whole place was smiling!

  22. Thanks for that. I went to a pain management doctor a while back, told him my issues and he basically tried to sell me a spinal cord stimulator. He said belbuca would be like water compared to 90mg morphine. Left me very depressed.

  23. I currently take 90mg/day of ms contain for failed back surgery from herniated disc. Have extreme issues of urinary retention and what seems like very low testosterone. Would Belbuca make a significant difference in these side effects with similar pain relief?

    1. Belbuca could work as well or better. Buprenorphine has been shown to have a lesser effect on reducing testosterone compared to traditional opioids like morphine. You may need to supplement testosterone for the short term, but it may normalize after several weeks if you are switched to Belbuca. There are some medical reasons that preclude testosterone supplementation, and that should be discussed with your doctor.

    2. I was on fentanyl for severe chronic pain and switched to belbuca about 4-5 months ago and I love it!! It works much better than the fentanyl patch!! I have alot more pain relief during the day and can actually sleep better now! Its worth switching but you need the proper dose.

      1. Shelley- I am glad to hear Belbuca is working so well for you! Recognizing each person needs individualized dosing, may I ask what dose of Belbuca you take, how you were titrated to your effective dose, and what dose of Fentanyl Patch had you been on? Chronic pain feels like a prison sentence and I’m yearning (albeit, guardedly) to be set free. Thank you!

  24. I just want to confirm my conversation I had with my doctor. I have severe lower back pain caused by several car accidents and a fall 7 years ago. I have several herniated discs in my lower back and now they think it could be my SI joint since injections have not worked. I initially was prescribed Ultram and had a bad reaction to it, thought I was having a heart attack and had to be admitted to the hospital. They started me on Hydrocodone 7.5, which I was scared to take anything since I thought it would send me back to the hospital. I have a very low tolerance.

    I would take half of the pill and just recently am close to taking the whole thing. Just a weird thing I do to make sure I can build up a tolerance to anything. If I take the full 7.5 it feels like my breathing becomes labored and I start freaking out which makes things ten times worse. I’ll drink like a gallon of water to dilute the dose if I start feeling weird. The only good thing is that the hydrocodone does give me relief. I was on Lyrica etc. non of it worked. I would not be able to get out of bed in the morning without it. I have the worse time sleeping at night as well and sleep on a heating pad due to the pain. Have not gotten a good night sleep in years.

    So the doctor prescribed me Belbuca 150 and I am doing so much research to make sure I won’t have the adverse reactions as with hydrocodone. My doctor told me that it is safe and that 150 Belbuca probably won’t even effect me at all and that they will have to increase my dose next month. I am scared to take it because I believe since it lasts 12 hours in your system that if I have a adverse reaction to dose there is no way to counter the reaction and I will be screwed up for the next 12 hours.

    From what I have read it is fairly safe, especially with the side-effects . I am just trying to get a second opinion to put my mind at ease as to the safeness and is 150 Belbuca as strong as a 7.5 hydrocodone? Any insight would be much appreciated. Thanks

  25. I have been taking 2 mg suboxyone and weaned off of it for 19 days and lost 40+ pounds. I asked my doctor for a low dose of belbuca since I am trying to wean off of it. Currently I am on 450 of belbuca a day and it does help with my neck pain which I had terribly after suboxyone. Do you think belbuca is the right route for weaning off suboxyone and eventually feeling better?
    Thank you!!
    An email reply would be nice and helpful.

      1. Thanks I’m just trying to get used to how they stick properly in my mouth … they get stuck in my teeth and I think they don’t work sometimes because of that .

  26. Hello,
    I have been taking suboxone tabs for a long time. Almost 10 years. I really want to stop but don’t know how to do it properly.
    Any advice would be greatly appreciated.

      1. Thank you for that. As it turns out, that’s exactly where I am now and have been for 10 years. It’s a suboxone program that saved my life but I think enough is enough. I just can’t seem to stop taking this stuff. At lest I’m a functioning member of society now.
        Anyway, thanks for your time.

  27. Hello doctor,
    I was taking percocet 10/325 prn 3x daily & MSER 15mg q12h. For avascular necrosis of the hips in preparation/wait for surgery I have bobbled between 60 and 90 MEE daily for a bit more than a year.

    My doctor removed the MSER and replaced with 15mcg butrans it took about a week to get the prior auth and I’ve been suffering meanwhile. I have taken a bit more than normal of my percocet as my pain has been under managed. It takes 72 hours to achieve stable plasma levels of butrans from my understanding. Would you imagine my percocet will be less effective during the transition period? I’m very concerned with initiating butrans as my current regiment is not sufficient and if it takes 3 days for the butrans to work and in the interim it is also making my percocet less effective it seems I will be grossly undermanaged. So i have 2 questions:

    A. Should I expect that I will need to deal with increased pain and diminished effectiveness of my current medication (how much stronger is affinity of buprenorphine than oxycodone? Is there a better rescue med to be used during the transition which u could speak with my doctor about?

    B. Is initiating butrans approximately a month prior to hip replacement surgery a good idea? Obviously you cannot give medical advice, but if it makes traditional pain management less effective will it cause issues with my pain management post surgery? It seems bilateral hip replacement will be the indicated treatment, though I will be reviewing MRIs with surgeon next week. Would it be a good idea to talk to my pain management doctor in regards to diminished effectiveness of post surgical pain management due to butrans? Or should I not be concerned?

    C. When titrated for discontinuation is butrans going to be more difficult to stop in terms of withdrawals? Or will the process be similar or the same? I read that longer halflife of the drug can make the discontinuation and the time of acute withdrawal symptoms greater is that accurate?

    1. Would you imagine my percocet will be less effective during the transition period? Perhaps, because it may precipitate some withdrawal

      A. Should I expect that I will need to deal with increased pain and diminished effectiveness of my current medication. Probably because the Butrans dose is low, not because buprenorphine can’t work.
      How much stronger is affinity of buprenorphine than oxycodone? MUCH stronger, but at the 15mg dose, there will always be some unoccupied receptors.
      Is there a better rescue med to be used during the transition which u could speak with my doctor about? Yes.

      B. Is initiating butrans approximately a month prior to hip replacement surgery a good idea? No
      Obviously you cannot give medical advice, but if it makes traditional pain management less effective will it cause issues with my pain management post surgery? Possibly, but this can be overcome if you have a knowledgeable anesthesiologist and pain team.
      It seems bilateral hip replacement will be the indicated treatment, though I will be reviewing MRIs with surgeon next week. Would it be a good idea to talk to my pain management doctor in regards to diminished effectiveness of post surgical pain management due to butrans? Yes
      Or should I not be concerned? Yes
      If we have a patient on Butrans, we stop it the week before surgery.

      C. When titrated for discontinuation is butrans going to be more difficult to stop in terms of withdrawals? Not at your current dose.
      I read that longer half-life of the drug can make the discontinuation and the time of acute withdrawal symptoms greater is that accurate? No, the half-life has nothing to do with precipitating withdrawal. I fact, a longer half-life can be beneficial i blunting withdrawal, because it is a physiological natural taper.

      1. Thank you so much for all your answers! So my last question is which medication would be a better rescue medication for me to discuss with my doctor?

      2. Which rescue medication cooperates with buprenorpine better than oxycodone? Is there a recue med that has a stronger affinity?

        thank you for your help!

        Best,
        Adam

  28. Jeff,
    Thank you for the informative article and responses. I have chronic severe pain from EDS and multiple comorbidities. I was on tramadol 300mg/day. Then butrans 5 for a month, then butrans 10 for 2 months. Then I reacted with swelling and chemical burn like blisters at the patch site. After a month back on tramadol, my insurance has approved belbuca. My pain doc was unfamiliar with dosing so originally wrote for 75mcg every 8 which was denied, but I was able to get 75mcg every 12 as it is supposed to be. My question is how does 75mcg belbuca every 12 compare to butrans 10 patch weekly?

    1. Belbuca is 45-60% absorbed (so let’s sat 50%) and Butrans is 15% absorbed.

      Belbuca is about 50% absorbed.
      75mcg twice daily is therefore (75mcg)(2) = 150mcg (0.5) = 75mcg absorbed per 24 hours

      Butrans 10 is about 15% absorbed
      10mcg/hour = 240mcg per day (.15) = 36mcg absorbed per 24 hours

      Therefore you current available buprenorphine dose with belbuca is a little more than twice what you were getting with Butrans 10 over a 24-hour period of time.

      See https://www.pharmacytimes.com/contributor/jeffrey-fudin/2016/03/a-brief-review-of-buprenorphine-products

      1. Dr. Fudin,

        First, thank you so much for sharing your knowledge regarding Buprenorphine; it has been so invaluable to me during the last several years and I often look to your website as a resource.
        I apologize that this question isn’t pertaining to Belbuca, but I’m frustrated with the lack of understanding and information out there regarding Bupe.
        I’ve been on 5mcg Butrans patch for 6 years and it has worked fairly well in reducing my pain. I now feel it is time to stop using it and neither my doctor nor my pharmacist have any clue as to how to go about that.
        Since I’m at a pretty low dose, do you think one would be “okay” simply taking it off and going cold turkey? Or can these be cut in half and titrated down that way? Nobody seems to know if these can be cut and how to safely wean off of them. I’d really appreciate your advice!
        Thank you!

        1. Yogamom, The patches should not be cut. Overall the dose is pretty low. Speak to you doctor about simply removing the patch, and ask him/her to provide clonidine or Lucemyra if medically appropriate on an as needed basis to treat any sign or symptoms of withdrawal, which overall should me minimal.

  29. Hi Dr. Fudin,

    I read through all the posts and I’m still not sure if I should be off norco 20-30 mg/day for a minimum of 24 hours before I start taking the 75 mcg Belbuca my Dr. rx to me?. I was put on 4mg of suboxone 1 year ago to help with my much worse opioid problem. I was off norco for 24 hours and only took 1 mg (cut a 2mg in half) suboxone and that little dose of suboxone through me completely off balance and started making me panic. I called my psych and she said maybe the norco was still in my system and I was experiencing w/d symptoms. I am afraid that the belbuca might do the same thing to me, I am scared to take it today. I will be off norco for 24 hours in about 1 hour, what do you suggest?
    Thank you in advance!

    1. Lesle, I cannot give you medical advice on this forum. Some doctors prefer to taper the opiates all they way down very slowly prior to starting Belbuca in order to prevent withdrawal. Others use it for breakthrough pain. You should discuss this with your psychiatrist. Sometimes anxiety and panic are confused for withdrawal, but in some instances all three are present.

          1. In what way are they different.

            Humans have addiction to so many things
            EGO is the biggest one. Food is huge

            Most doctors truly believe this health care system is a viable solution when in reality it is all poison. From the insane people who basically have a new religion to the doctor.

            It’s training that gives the doctor the feeling he is a God. Then the patients who question nothing because God told them what to take.

            The reality is this is a huge money game. The doctors have no clue yet even here listen to the way they answer like they are so sure.

            Unluckily we are one body. Not little parts and you can treat this problem and that’s it. We are not card. Our whole body must be treated together with the mind.

            TV news and Doctors are the brainwashed society we live in.

            Remember Andrew Carnegie and Rockefeller created the AMA as a for profit venture. They made real medicine that truly treated the whole body as quackery then the litterally created the hell we are in now.

            PTSD. Everyone has it according to these quacks. Yes they do not know any better but most of you do.

            Controller the mind and the body will follow. Unluckily that is what doctors do most unknowingly.

            Homeopaths are the only healers in the West. Cancer is rampant because of diet. All illness can be cured with proper diet and meditation. It’s quite difficult though after 50 years of brainwashing by quacks.

  30. I was on Hysingla and Norco for several years for severe chronic back and SI joint pain. A new doctor took over the practice and over the past two months he lowered my total dose of Hydrocodone from about 52 mg to 35 mg. I was not getting adequate pain relief change me to Belbuca 150 mg twice a day a few weeks ago.

    I was already not receiving enough pain relief before I was scheduled for a surgery. I started the Belbuca two weeks before I found out I had to have surgery for liver cyst deroofing. I had done research about using Belbuca before surgery and not getting enough pain control afterward but my pain specialist insisted I would be fine.

    When I got to the hospital the anesthesiologist told me he was wrong and they would have to use different IV meds immediately after surgery. He didn’t tell me what they were. I just remember being in quite a bit of pain in the recovery room even though the surgeon didn’t think the pain would be too bad. He also did an umbilical hernia repair, which was not planned and I feel that is causing me the most pain. I was given a dose of Norco before I left the hospital. It was an outpatient procedure. I was in a ton of pain and it has continued today. I am currently on the 150 mg of Belbuca twice a day and 5-10 mg of Norco every 6 hours. The Norco helps slightly but not very much. Because I’m on the Belbuca is it possible for the Norco to still work?

      1. I wasnt sure how to post a comment so I clicked “reply” hoping to get a response bc I desperately need some advice/help. In 2013 I was diagnosed w/fibromyalgia and since being diagnosed I have seen several doctors and been on so many different medications I’ve lost count and many of them I’ve had adverse reactions to. One (Celexa) actually made me pass out in the middle of the grocery store so I developed severe anxiety against taking/starting any new medications. I started taking pain medication on my own since it was the only type of medication my body did not react badly too and I could not get doctors to prescribe it due to my age and them not believing how much pain I was in on a daily basis. 5 to 6 years later I’m tired of having to buy pain medication illegally I started researching suboxone and subutex for pain relief and found many favorable forums and reviews for how well buprenorphine works for pain. I set up an apt w/ an addiction clinic and told the doctor I was “addicted” to pain meds so I could get a script for the suboxone. I explained my anxiety to her about starting new medications so she started me off on 8mg twice a day. I was nervous, still, and decided to take 4 mg and not even an hour later I got extremely sick and got dizzy and light headed upon standing and felt that I was going to pass out. (It had been over 24 hours since my last dose of opiods) called the doctor and she said that I was having an adverse reaction to the medication and to only take 2mg the next day. I did as instructed and still felt nauseated, weak, and lightheaded and almost uncontrollably sleepy/tired but my pain was controlled almost 100%. I was up cleaning house, playing with my kids, even took them to the park in whereas without pain medication I could not do any of that. Saw her again today and she decided that I should try subutex, the script w/o the naloxone. She said with some patients the naloxone in suboxone can cause the headaches, weakness and nausea but also said that subutex is a bit stronger than suboxone but I cant find anything that suggests one is stronger than the other or that naloxone could be the reason the medication is making me feel so sick. So I guess my question(s) is/are, has my symptoms that I’ve described in any way associated with the naloxone and is there any indication that subutex is stronger than suboxone? Also, if subutex is in fact stronger than suboxone should I start with a lower dose to try and minimize any side affects that it may cause?
        Thank you for taking the time to read and respond to my message, any input/advice will be greatly appreciated!

        1. DBoz, Buprenorphine by any brand name is still buprenorphine. The buprenorphine is Sebutex is not different than that in Suboxone. The absorption may be slightly different between the two, but that is negligible. No, naloxone will not block buprenorphine effects at these doses if used as directed and should not cause headaches. I believe that Sebutex is the better choice anyway because there is no need for that naloxone.

      2. Dr. Fudin,

        I began 2019 taking 2mg of Dilaudid 4 X day, 10mg of methadone 2 X day, Flexeril as needed and 10mg of Ambien for long-term osteoarthritis, since 1995. I had been on the above mentioned tegime for almost 3 years and I was reasonably comfortable. Knee replacement is coming, in 2021.

        I am 70 and have been on one form or another of opiod/pain relief/downer since I was 12 and my pediatrician prescribed Seconal. Addiction runs in my family, so I became an addict almost immediately. I t had been part of my.life since.

        I also had heart surgery on January 2. I got a cow’s aortic valve added to my own badly functional one, and two stents. I came home, and my pain doc is now wanting to change my meds due to the changes/crackdown on opiod use.

        He is not the bad guy, only the deliverer of the bad news. But I have not been comfortable since!

        I take the methadone to reduce the cravings. So the doc took away the Flexeril, and immediately dropped my methadone in half. According to my state pharmacy board, that takes me down to about 70-72 morphine equivalents per day, which is pretty reasonable for someone with my history. But the methadone does nothing for my pain, so I am kinda screwed right now.

        This month we changed my strengths to 5mg of methadone 3 X day and 2mg of Dilaudid 3 X day. And he suggests I research belbuca and beltrsns patch. So my questions are:

        Will the belbuca keep my pain AND my cravings down? and

        Do I have to go off everything for a week before I switch to belbuca?

        May I continue to take Dilaudid for breakout pain while I am on belbuca?

        I understand you don’t have my history, but thank you in advance for whatever answer you can give me.

        Sincerely,

        Susi

        1. Susi,

          You case is too involved for me to answer these questions without a complete medical chart review. If you are interested in that service, I’m happy to provide a consultation upon request from your doctor.

          1. I would like to say that I consider your forum quite wonderful in that you, of such credentials, have extended yourself to those that have serious issues that will not be misled. That you Dr.., thank you on behalf of all in pain. My your residents adopt this attribute.

  31. Hi I have chronic knee pain from have my knees replaced 15 yrs ago and numerous surgeries after that. I also have that disease where I make scar tissue and my body wont dissolve it. I was one methadone for 10 yrs but the pain clinic closed so the new place put me on levorphanol but after 6 month because of the cost my insurance they no longer wanted to pay for it. So they tried me on Oxycontin but my stomach ached like crazy I lost my appetite and wasnt eating for like 2 1/2 weeks and lost 25 lbs. So finally they took me off they switched me to oxycodone 5mg for 2 weeks then I’m starting butrans patches 7.5 mcg. I know without seeing me it’s hard to tell but just curious do you think this medicine would work compared to what I had been taking? The doctor said he doesn’t want to put me back on methadone cause of the way our bodies absorbs it cause I also have stage 3 chronic kidney disease. I also take blood thinners, nerve pain meds, cholesterol, b12 injections, iron pills, and meds for my kidneys

    1. Chuck,

      I do not think it will work as well as levorphanol and it is inappropriate for the insurance company to deny levorphanol if your responded well to methadone. If you can go back on methadone, that is acceptable with CKD. Levorphanol and methadone have a similar mechanism of action in that they both block NMD in addition to their opioid activity. Your doctor should be able to make an acceptable appeal to the insurance company for levorphanol. He can use Pham TC, Fudin J, Raffa RB. Is Levorphanol a Better Option Than Methadone? Pain Medicine. 2015 September; 16(9):1673-1679. If you send me an email to jeff@paindr.com, I’ll provide a copy of the article.

  32. Hi. I have been on Belbuca for about 3 years or so. I suffer from Sjogrens Syndrome. Besides dry eyes and dry mouth, I have horrific neuropathic pain. I was on morphine 15 mg, but my doctor ran a genetic test to see how I metabolized medications. I came back that I do not metabolize morphine effectively. So, up steps first Suboxne. I just could not handle the bitter taste so my doctor had me try Butrans. Naturally after about two months of use, my shoulder had an angry red mark that mirrored the patch. Now my doctor has me try Belbuca. I am on 750 mg. It is an adjunct to Lyrica 225 mg for the neuropathy pain. Lately I have experienced some very weird and disturbing symptoms after placing patch in my mouth. Extreme tiredness (even though I am on 200 mgs of Provigil), chills, and nausea. I took Belbuca at 6 am as usual. Around 10 am the symptoms were in full effect. I also have muscle twitches too. Anyhow, the symptoms finally abated as in the past about 18 after my morning dose. Each time I did not do my evening dose. My question is have other patients reported these symptoms? I may have to handle the bitterness of suboxone or go back on Low dose Morphine 15 mg.

    1. Harry, A genetic test would not show you can’t metabolize morphine. It does not require metabolism that is generally dependent on genetic polymorphism. Regarding you question on new symptoms with Belbuca, I haven’t ever seen that. There’s no reason to believe that you wouldn’t have the same reaction, and perhaps worse with Suboxone, since the latter is a higher dose. You should speak with your doctor about giving a lower dose of Belbuca every 8 hours.

    2. I too had those symptoms, but found if I eat before using the patch I do not have those symptoms. Hopefully this helps

  33. Hello doctor you helped me once before I have mad respect for you I truly mean that from my heart…. I suffer from mental illness and also addiction. Undiagnosed wish bipolar 1 ADHD and social anxiety key… I take Suboxone 24 mg a day. Adderall XR 50 mg a day. Gabapentin 900 mg 3 times a day. Lithium 300mg aripiprazole 20 mg and sourcing 300mg. Sexual 2000 my first question is is it okay to take all that medication also… The lithium has gave me psoriasis i’m going to go to a dermatologist next month but I have it all through my scalp and on my face the doctor lower the toast of the lithium but we’re talk to you about a new type of medicine to use do you know the names of the new medicine that’s out for something like lithium there’s supposed to be a new one on the market for bipolar?????? Also doctor is it okay to take all those medications every two months it seems I have a bad spell or side effects from it is it too much medicationand if you could find out that new drugs named please please help me thank you very much god bless you and your family

    1. Mike, I’d have to see the actual labe to comment or have a list of all the ingredients, as there are several products for sexual enhancement with 2000mg of something.

  34. Doctors,
    Buprenorphine did indeed get it’s start as a pain medication. It was introduced around 1986 under the brand name Buprenex, to be given IM with the selling point that the drug produced less respiratory depression that full agonists- all true, until one considers that most post operative patients have one benzo or another on board and a pre-op or intraoperative sedative, which explained why we had to intubate a few post op hip patients.
    In the early days, some people in treatment facilities injected Burpenex into “gummy bears” as an early form of “subutex.”

  35. I have been taking Oxycodone 10/325 every 4 hours for severe spinal pain. Doc just added Belbuca 150 2/day and didn’t change the other med. I’m not feeling any relief from the Belbuca. It doesn’t even feel like I’ve taken any medication at all. Are the side effects different because this is not a “typical” opioid?

    1. Katelyn, Side effects are similar, but Belbuca is safer fr a number of reasons. Your doctor will probably need to titrate the Belbuca dose upwards while gradually reducing oxycodone, the latter of which I suspect will not be needed as often once an adequate Belbuca dose has been established.

      1. Giving Buprenorphine to someone that is on opiates is very dangerous as it can cause withdrawal. I highly doubt any Doctor did this. Someone needs to be off opiates completely for at least 24 hours just to start a medicine like Belbuca. They are NEVER given together.

        1. I have been prescribed suboxone a few times (which is a brand name of buprenorphine and naloxone) on a couple of different occasions and not once did the dr tell me to stop taking other opiates for 24 hours before. I’ve never had a problem mixing oxycodone and hydrocodone with suboxone as well.

        2. I am currently taking bulbuca 450 and oxycodone 15 mg q 6. I suffer with depression. I have wide spread pain. I took lyrica short term and thought it helped but I developed severe memory loss. Continue to have problems with memory.
          Any suggest?

        3. Concerned reader,
          Yes they are given together by a Dr. . Our pain management has us on both oxycodone and buprenorphine.

        4. Sorry, but you are not correct. Unless you are a pain management specialist please realize there are many ways to prescribe medications, and that one of the options is just this.

        5. You are thinking of suboxone. It is buprenorphine and naloxone. The naloxone is what caused withdrawal. It is used in opioid dependency . The discussion is about pain management with buprenorphine.

          1. Jan, This is an incorrect statement. Buprenorphine has a higher binding affinity to mu receptor than does naloxone. It is a complex pharmacological concept. Once buprenorphine attaches t the receptor, traditional opioids need to compete with it for the receptor. Since buprenorphine is not easily displaced, that’s what causes withdrawal, not the naloxone. In my mind it’s ridiculous that naloxone is even in the product.

        6. Belbuca does not contain naloxone and so does not have an opiate antagonist that will cause withdrawal if taking opiates/opioids in combination with it.

          1. JB, It is not the naloxone in Suboxone that causes withdrawal. Buprenorphine binds even more tightly to the opioid receptor than naloxone. See several of my previous comments regarding this.

        7. I’ve been on opioids for too many years, was on Oxycontin 10mg x 2 & Oxycodone 10mg x 3 a day. My pain specialist started me on Belbuca 75mcg 2x day & stopped the oxycontin. I had NO withdraw symptoms. The following mth she increased Belbuca to 150mcg x 2, then to 450mcg. My pain is better than it has been for years! More days than not I’ve been able to decrease oxycodone to 2 x day. Bebuca has been a miracle drug for me. I cant even tell that I’ve taken anything…no euphoria feeling at all! My mind is clear & I’m more active.

        8. I beg to disagree..
          My pain management did so and still does all the time…
          The Belbucca is for around the clock care (1 every 12 hours)
          The Oxy is short acting and as needed..
          That’s what I do know however, I agree (point I brought up with my doctor) if the Bellbuca blocks pain receptors why would you give me oxy too.. and he told me just what I told you.
          With that said sadly so many times patients dont read all the mice type and go simply by what their doctor in office tells them.
          It explains all that in the minnie mice type..

          1. At the lower doses of the BELBUCA I was still having breakthrough pain. As my doctor increased the BELBUCA my breakthrough pain decreased so didn’t need as much oxycodone.

        9. Wrong answer. I have been under careful supervision with my pain doctor. He has titrated me very very slowly with the Belbuca. I’m still on Percocet 10/325 three times a day. Eventually I will be to the point where I don’t take the Percocet at all. Because the Belbuca has a higher affinity and will win out over oxycodone every time

          1. I’m now taking Belbuca 650 mcg and it’s working so well! I’m in the process of cutting the oxycodone down to 1 x day! It’s such a relief to be on a med that works WITHOUT the euphoria feeling! I still feel the effects of the oxycodone but nothing like it was. My goal is to discontinue the oxycodone completely. I’m so grateful for BELBUCA!

      2. I have adhesive arachnoiditis of the lumbar spine. I am doing very well compared to what I have heard about others with this- I stay active, but live with pain. I have been under the care of pain management since the late 90s. I have taken Oxycontin, Fentanyl, and methadone- I stopped taking them all on my own. Deciding to discontinue methadone was like dying and going to hell- horrible side effects that lasted months. I had no idea when I was prescribed that medication that very few people actually get off of it. In the last few years I have had spinal injections and a spinal cord stimulator. I had an allergic reaction to hydrocodone and have taken Percocet over the last couple of months- very little of it ( half a low dosage tablet before bedtime). I also take 150 mg of Lyrica, which works well but I cannot take it duing the day due to dizziness and blurry vision. Fast forward to Belbuca- my doctor wanted to try me on 75mcg of this medication. I agreed to try it, but I am very afraid of having something similiar to my methodone experience if I decide to discontinue it. Am I over-reacting? I really like my life and don’t want to go through the hell I went through before.

        1. As long at the Belbuca is titrated by a professional that knows what they are doing, it shouldn’t be a problem. The same could be said of methadone. For the record, YOU ARE NOT ALLERGIC TO HYDROCODONE; if that were the case you would not be able to tolerate oxycodone or buprenorphine. I’m telling you this because if that is in your record, it may preclude doctors in an emergency situation from giving you many drugs, including those listed, morphine, and many others.

          1. I personally discovered, not the med itself is to blame for what seems like allergies. The fillers in different generically filled meds. And constantly switching generics is a problem for some people. Like me.

          2. Thanks for your reply. You cleared up the issue of hydrocodone- I had taken it in small does for quite awhile than started getting a rash and itching. Couldn’t figure it out. Thanks, again for your frply.

      3. I’m on 12mg of suboxone, can I switch to Belbuca the next day and if so how many mcg of Belbuca to take

        1. 12mg of Suboxone equals 12,000mcg and is 30% absorbed, which equals (12,000)(0.3) = 3600mcg

            Belbuca highest strength is 900mcg twice daily which equals 1800mcg, and is 50% absorbed, which equals (1800)(0.5) = 900mcg

          1. Dr. Fudin,

            At one point was on 300mg/day tramadol – never worked well, signs of serotonin syndrome.
            Then took Nucynta 350mg/day (titrated up) for a year (worked decently-good) when insurance changed their minds about coverage. Cut to end of that crappy story – Dr. moved to Butrans 20mcg/day.
            Then, new Dr. (I moved away) put me on 8mg/day suboxone – pain relief very minimal-not good.
            8-10mths later Dr. changed back to Butrans 20mcg/hr patches, because to me they provide better pain relief than the suboxone (at any dose really).
            Now I have issues with the patch’s adherence, limits to my motions, and mainly I can feel a big drop-off after day 4-5 per patch.
            So Dr. says could rotate Butrans every 5 days instead of 7 (which I highly doubt insurance will agree to); but Belbuca did come up. Before I read anything about Belbuca Dr. said it dissolves in your mouth (cheek), similar to suboxone (tongue) so right away I thought ‘its not going to work nearly as well for my pain relief.’ (relative to Butrans)
            ———–
            I understand that absorption rates are different per person also per route, also I assume some tolerance issues are at play.

            8mg Sub = 8000mcg(.3) = 2400mcg per day
            20mcg/h Butrans = 480mcg(.15) = 72mcg per day
            2x 75mcg Belbuca = 150mcg(.5) = 75mcg per day
            -So these absorption coefficients must be off because it was an obvious, positive difference going from suboxone to butrans.

            *What I cant understand is why would a lower dose of overall bupe create better relief in an individual? Also, if “bupe is bupe” why is the ceiling of Belbuca able to be double (or more using coefficients provided) the ceiling (according to QTc references) of Butrans? To me that suggests bupe is not bupe…internal breakdown/metabolism tree is somehow a different ‘profile.’

            **Real question is do you think Belbuca would be a useful move from Butrans 20mcg/h based on info provided? If so, at what Belbuca dosage would you guess to be equally therapeutic to current 20mcg/hr Butrans – not starting dose to titrate up from; end point guesstimate?

            ***Also wondering if tolerance in bupe arena is similar (time wise) with full agonist opioids? Not planning on dying anytime in the next decade (so the only real path will almost undoubtedly end up with Belbuca)…

          2. The Belbuca should work as well or better than Butrans. The qTC interval is the same for all buprenorphines at relative like doses. The reason you may not have responded well to Suboxone is because of the naloxone content.

    2. “Katelyn, Side effects are similar, but Belbuca is safer fr a number of reasons. Your doctor will probably need to titrate the Belbuca dose upwards while gradually reducing oxycodone”

      What are you talking about. You would NEVER give opiates with Belbuca or suggest what you suggested. One has to be off opiates to start Belbuca. It is advised they wait 24 hours after the last opiate dose.

      1. When on lower doses of Belbuca (or Butrans patches), not all of the mu opiate recptors are occupied. So, there will be some benefit with oxycodone. As the buprenorphine dose increases there are less unoccupied receptors, so oxycodone will not work.

        1. Looks like DR. Fudin had to comment to show daviddc is incorrect, Taking Bup after high doses of Oxy causes serious withdrawal 30 min or less hence the mandatory 24hr delay in administering Suboxone. Don’t comment on others.

  36. Legally disabled due to Chronic pain for 14 years. 2 failed back surgeries, degenerative disc disease and arthritic spine. Every other drug and procedure was tried before fentanyl patch. Has never taken away all of my pain which has worsened. Opioid and NSAIDS resistant. 200 mcg fentanyl patch and Doc suggested increasing dosage and I said wait. ZERO a month ago because Doc closed. No other will. What the hell am I supposed to do now? Only 57. Wife and one child 13 years old. Another medication I have not heard of? Another state? Another country? Discseel did not work and I paid $20,000 out of pocket. Is the AXOLOTL SHOT ™ regenerative a waste of time for my condition? Arizona

    Rod

  37. My dr has treated my addiction for 3 years and currently taking 6-8mg buprenorphine sl a day well she switched me to buttons 7.5mcg and I feel like absolute garbage. It’s my understanding that 1000mcg in a mg and taking 7.5 mcg an hour is no where close to my usual dose why would my dr switch me like that? I have a feeling she is just guessing

      1. I have an intrathecal pain pump which had Dilaudid in it, at almost 9mg and I wasn’t getting adequate relief. My doctor and I decided to change the medication in the pump. I was put on Belbucca 150 mcg BID during the tapering process; it was like taking Tylenol, actually I think Tylenol works better! Not to mention all the side effects…I have taken Subaxone 8 mg/ 2 mg before getting my pain pump, and Belbucca can’t hold a candle to Subaxone`s effectiveness. Not sure if it’s because Belbucca is mcg’s, where Subaxone is mg’s but whatever it is Subaxone is way better for my chronic pain!

        Laura J.

  38. I have suffered with chronic pain for 16 years and have been on tons of different opioids. This month my Dr switched my from 10mg ocycodone 5 x per day to 2mg of dillaudid 4 x per day and it’s like I’m not taking anything at all. Today he prescribed 150mcg of Belbuca 2x per day, how will that work with the dilaudid? I thought that you couldn’t take buprenorphine with opioids or it would give you withdrawal effects and cancel out the opioids. Can you help me understand?

      1. Like I mentioned I had been been on Oxycodone 50 mg a day and 50-60 mg for the past year and a half and all of a sudden at my monthly appointment my doctors said he was switching me to dilaudid( and sorry my dose is 2mg q5hrs) and his NP said he was trying to switch all of his patients to it as well. I returned today to have steroid injections into my back and brought up the fact that I had been extremely nauseated (called in Zofran Friday) horrible headache, anxious feeling and he asked me about one medicine I had never heard of and I mentioned having something that was long acting then use the low dose 2mg dilaudid for immediate release break through pain and that’s when he prescribed the Belbuca. I did get it filled today but was told by the pharmacy most patients only use it for a month or two due to being unaffordable for most and lack of affectivness for those with chronic pain. Do you recommend I take it or is there another long acting medication/patch that would be more effective? Thanks so much for your responses

        1. Short acting opioids such as Dilaudid are sometimes used for breakthrough pain while titrating the dose of long-acting meds. But, the short-actings should not be continuously used on a regular basis.

      2. I’m a little confused at your statement. I was on suboxone for years then was injured badly. And am very familiar with all opioids and opiates. Why would belbuca cause withdrawal if it doesn’t have nalaxone? From wheat I understand you can take belbuca and a short acting opioid? From what I’m aware of bupenorphine binds well to receptors but idles it aid to block other opioids if it doesn’t have nalaxone?

        1. Buprenorphine actually has a higher binding affinity to opiate receptors than naloxone. But buprenorphine is a partial agonist/antagonist so it does have analgesic properties. Naloxone is an antagonist only. Depending on the dose, if buprenorphine is occupying all or moost of the receptors, a full agonist opioid will not be able to get to the receptors. If a patient is on oxycodone or morphine or another traditional opioid, as soon as it leaves the receptor, buprenorphine will grab that receptor and stay there, preventing the full agonist opioid from having activity.

          1. What are your thoughts on using Belbuca for long-acting pain relief and Nucyunta for BT p? What are your thoughts on the Nucyunta’s efficacy w/ Belbuca (say,300 bid). Thanks!

          2. Dana, I’m okay with the combination if prescribed and indicated, but not the extended release Nucynta for breakthrough pain. That should be the short-acting lower strength formulation.

  39. Hi Dr Jeff. I don’t know if anyone else has mentioned this problem, because I don’t have the time to read all these comments. Impressive!

    I’ve been using Belbuca for a variety of mostly spinal and structural issues for nearly three years. For half that time, more or less, I’ve had a problem that’s about to make me give up on its benefits.

    One background point: about 12 years ago, I developed an allergy to mint. I used real mint toiletry products and developed severe dermatitis on my lips, itching and pain in my mouth, and headaches. After I quit the mint, those symptoms went away, and I’ve been good at avoiding it overall.

    Unfortunately, Belbuca is flavored with mint. Between that and its plastic knife-ness, it has damaged my cheeks. I alternate sides, morning and night. Product instructions say it dissolves in about 30 minutes. Ha! I have a dry mouth and it can sit there for literally hours.

    Consequently, I have large, painful sores in both of my cheeks. Sometimes they are open canker sores. Sometimes not. Either way, it is painful to eat anything that isn’t soft or bland. Trail mix hurts. Spicy hurts. Eating hurts. Every day. If I actually had an appetite (thanks perhaps to tramadol?) I don’t know what I’d do.

    I guess I don’t really have a question. More of a – my mouth hurts. But, have you seen this before? Do you have any suggestions? Paranoid thought: can repeated mucosal tissue distress/damage cause cancer? Because if I didn’t know it was caused by Belbuca, I’d be terrified I had mouth cancer.

    Thank you for your time, and for keeping up with this thread for three years. I’m glad I found you. Melissa

    1. Melissa,

      This is the first I’ve hard this issue. If the patch is causing mucosal soreness due to a true allergy, I am not aware that this could lead to oral cancer, not have I ever seen such a thing. Since you’ve had a problem with mint in the past, it does make sense that it’s an allergy. The was I see it, there a a few choices…

      1. Butrans won’t be an option, because the dose will be too low compared to Belbuca
      2. As your doctor to put you on Sebutex (or another buprenorphine product FDA approved for opioid use disorder off FDA labeling, even though that is not your problem). This could be justified because of your history as described above
      3. Speak to your doctor about using dihenhydramine liquid as a mouth swish and spit, or an oral non-sedating antihistamine. Before doing either of these, it’s very important to speak with your doctor or local pharmacist, because each of them has access to your history, and I don’t.

      1. Thanks for such a quick, thoughtful answer.

        1. I tried Butrans first. I didn’t realize I couldn’t go back, but I didn’t really consider it. I quit because it only lasted me five days. Every week. Five good days, two miserable ones. But insurance controls how many you get a month, not you and your doctor. So that’s why I kept using Belbuca.

        2. I knew nothing about Subutex before now. Dr Mike (my pain doc) has hesitated to raise my Belbuca dose above 600 mcg, saying after you get above about 1 mg, the analgesic efficacy diminishes. I trust him, so I haven’t investigated the veracity of this claim. Should I? Can you supply any article links for Subutex for pain?
        Also, jumping from 600 mcg to 2 mg (the minimum for Subutex?) sounds extreme.

        3. I’ll check on the diphenhydramine rinse. I already use oral antihistamines every day.

        Thank you!

        I wonder how I’d feel if I weaned off of EVERYTHING. Would I feel good? Or would it kill me? I bet everyone here wonders that sometimes.

          1. Same story here minus the allergy to mint.
            Shannonc115@aol.com
            10mg 4 times day to 2mg 3 per day of subutex.for over 15 years of chronic pain. Started with a back injury then arthritis and laat but not least a horrific internal injury from something I can’t explain in here.
            Sincerely;
            Shelly

  40. Regarding the third paragraph, wasn’t Buprenex the first FDA approved form of buprenorphine, and wasn’t its indication pain? Seems it was used for pain long before it became a treatment for addiction. Nevertheless, in my state, the off label use of less expensive generic subutex or any buprenorphine product except transdermal and Belbuca, is banned for used for chronic pain. Seems the tail (state legislature) is wagging the Dog (physicians) in some states.

  41. First sauce I would really like to thank you doctor for what you do…. I’m being treated by a psychiatrist 4 opiate addiction and mental health issues I have degenerative disc disease and herniated discs that put me in pain management and then I could not control taking my meds the right way so I ask for help the doctor has me on Suboxone 3/8 mg a day 24 ml mg total she’s using the extra 8 mg for pain she says I’m also diagnosed with ADHD when she has me on Adderall XR 50 milligrams also diagnosed with bipolar so I’m on lithium 450 mg and also when I came to the doctor I had a benzo problem I was on a 10 mg of Xanax a day she switched me to Valium to wean me off and it has been successful with detox…. Also diagnosed with social anxiety I’m not taking nothing for my anxiety I am just trying to confine it and put myself in uncomfortable situations so I can get used to it I do not sleep at all so the doctor has put me on many different medications the first was Seroquel made me gain 60 lb and then I started sleepwalking and falling down so she switched me over to thorazine it’s very strong but it works I sleep a full 8 hours with not waking up but it does have some side effects that I’m not liking at all my skin is very sensitive I am a redhead place already fair skin I live in Florida but when I started the story Zine my skin is very Ultra sensitive I’m also on gabapentin she uses that for nerve pain but I want to wean myself off of it and see if I can live without it my one big question is I want to switch to Belduce….is psychiatrist is not really wanting to switch me but I could probably get my primary care physician to do it since I will not go to pain management anymore I don’t even want to walk in the door of a pain management office knowing what that could do to me if I take the full energies okobi it again I have a year-and-a-half off all illegal drugs I am 50 years old and it’s the first time in my life that I’ve been clean but back to my question do you think if I switch what milligram will I need to be on since I’m on 24 of the Suboxone

  42. I’ve been taking 16 mg of Dino one a day if I was to switch to belbuca what mcg would I need to take to equal my 16 mg a day

  43. Interesting that an article from a few years ago still generates great response. I’ve been on 20mcg Butrans, Zanaflex & Hydrocodone for breakthru for many years. It took most of a decade to get a balance of meds/PT/trigger reduction that work for me and I feel thankful. My concern is the rising cost of the patches (use the generic but too lazy to look up spelling). New year = new deductible. My Rx is ready for refill and pharmacy said it was going to be $1,250 for 90 days. My insurance battles me about it all the time and wants my doctors to jump thru hoops because they hate paying for them…and my Dr tells me she thinks insurance is going to make it harder and harder to keep taking them. Why are the damn things so expensive? Is this a greedy $900 epi-pen U.S. pharma issue. Are they 5.99 in other countries and $1200 here? Opioid pills are cheap (and for me not as effective). I thought as drugs got older and generics started being available that price should be coming down…but seems to go up about 30% every year. does anyone recommend a cheaper alternative?

  44. Dr Fudin,
    PM&R doc with some limited experience using belbuca. I have a patient with Crohns/Ankylosing spondylitis with neck and back pain. Currently on Fentanyl patch 75u/hr, oxycodone 150 mg per day. He is having BP issues (fluctuating with the timing of patch) seemingly related to the Fentanyl patch and cardio would like to get him off of such. He tolerated no other long acting meds because of his GI issues, I would like to try belbuca, but he is on more morphine equivalents than recommended for transition. He refuses to go to a Suboxone providor, as he has only pain issues not addiction issues, and he knows there is a brief period of no opioids prior to induction and he is afraid of the withdrawal.

    1. Brian, According to the PPI, patients should be totally weaned off of full agonist opioids prior to starting Belbuca. Notwithstanding, in some cases that is not practical. Based on the current doses of full agonists, while this is complicated, especially with blood pressure issues noe, it certainly can be done. Please email me directly to jeff@paindr.com for more specific help. Thank you.

      1. Whats the deal with blood preassure issues. I am coming off Fentanyl 100mcg patch tomorrow. I intent on begining my belbuca 450 12 hrs after taking off my last patch. Will i need hospital help because of my blood pressure. I am very scared.
        James Ital my email is jimiital@aol.com can you please give me some advise please. As a badly disabled vet i have damaged neck and spine and a very close to death/ it’s a miracle in fact head injury 27 Staples two severed arteries. I’ve been on opiates for 10 years I managed pretty well but I’ve had enough. I only want to use the belt beuca for like 30 days then go solo. Is there any advice you can give me Doc please.
        Sincerly James Ital. Jimiital@aol.com

        1. James,

          Your doctor should taper down from fentanyl 100mcg before converting you to Belbuca. if you are n fact looking to completely come off of opioids, Belbuca is not your best choice. Instead, you should be enrolled in a detox clinic that uses high dose buprenorphine, a condition for which they are FDA approved.

  45. Hello,
    As a chronic pain patient i have been on close to 100mg of oxycontin. I decided i wanted to stop the pills, as i was obviously addicted. I currently take 8mg Suboxone. This drug has saved my life. The Suboxone provides enough pain relief that i am able to live with craving more.
    My question is what is the conversion of opioid /Suboxone
    And secondly, given the crisis with regard to opioids, why is Suboxone not being pushed forward as a substitute or replacement for opioids?
    Thank you very much
    Chuck

    1. Charles, Thank you for your note. I agree with you. Once the decision is made to place a patient on chronic opioid therapy, the FIRST line drug should be buprenorphine in the form of Belbuca or Butrans. regarding equivalence, that’s a very complex question that doesn’t have a simple answer. For that question, see Buprenorphine Conversions, where I explain it in detail.
      Regarding a discussion of your other question, see previous blog post here, Happy Holidays or Horrific Hoax? and focus on the paragraph as follows, and follow the hyperlinks for more detail.

      Since CMS refers to the CDC Guidelines as a gospel of sorts, they should also require that tapentadol (Nucynta) be a formulary item and prescribed in advance of traditional full agonist opioids, at least for chronic pain. In fact, the CDC’s CALCULATING TOTAL DAILY DOSE OF OPIOIDS FOR SAFER DOSAGE makes no mention of an MME for either buprenorphine or tapentadol, and for good reason… There isn’t one. For more info on that, see Academy of Integrative Pain Medicine’s White Paper, Opioid Dosing Policy: Pharmacological Considerations Regarding Equianalgesic Dosing which clearly delineates the fallacy of morphine daily equivalents, especially with buprenorphine and tapentadol.

    2. Chuck,

      Maybe you or someone could answer my question. I broke my back in combat in 1991, but had a mission to complete and kept going. When I got back onboard ship I saw the doc. No X-rays and he gave me Motrin. Long story short, I kept going and 8 years later retired. Several docs just put me on morphine sulfate and Vicodin for 20 years. Finally had a surgery and neurosurgeon couldn’t believe I wasn’t paralyzed. Was taking 30 mg’s MS and 10 mg oxycodone daily. They weaned me Dow to two 15 mg MS daily. I took 30 mg MS at 1 pm today and a 5/325 Vicodin and it’s now 10 pm. Doc called in Subutex 2mg twice daily. I went two days prior today with no pain meds. Would it be safe for me to take Subutex tonight? Doc never said a word about it. Thank you.

      1. Hey brother, I was told 12 hour minimum between taking opioid and Suboxone, I would definitely check with Dr for specific directions

      2. U should be fine. I have a lot of “experience” and no I’m not a doctor but I was on the exact same prescriptions and they told me wait between 12-24 hours. So two Days should be plenty. Good luck! I’d like to know how you do!

      3. You can take subutex with pain meds. You can not take suboxone.
        Any drug clinic for dependency gives you 2-3 days of subutex before beginning suboxone for this very reason.

        I suffer from chronic pain. Was addicted to oxycontin for years. The Dr gave me subutex first in case I had oxy still in my system.
        Subutex you’ll be fine with other pain meds.
        Not Suboxone.
        One has naloxone the other does not.

        1. Michelle, This is not true. Buprenorphine binds more tightly to opioid receptors than naloxone. Any full agonist opioid (such as oxycodone) will have severely diminished activity at the mu opioid receptors when buprenorphine is present. In fact, one can make the argument that buprenorphine alone is worse than the combo in that regard, because naloxone is floating around the receptor that is occupied by buprenorphine. The overall dose of bupenorphine is more important than whether or not naloxone is present.

  46. Hi, Doc.

    I’ve been using Butrans 10 patches for several years for chronic pain, to establish a good baseline of pain relief while tackling the condition mostly with steroid injections, nerve ablation and physical therapy. I figured it was a safer alternative to taking hydrocodone or oxytocin. Meanwhile, I’ve developed Stage 4 esophageal cancer, which will be presenting its own pain challenges as my treatment goes along. My chemo schedule has severely limited the physical therapy that helped me before because of my fatigue. Complicating matters, my insurance company no longer wishes to pay for the rather expensive Butrans patches. Whereas once the patch was a good idea, I’m now seeing it might be a good idea to just go over to the hydrocodone for now, since I’m already using hydrocodone as auxiliary to the patch. Can I just give up the patch, cold-turkey, and rely solely on hydrocodone (w/acetaminophen 10-325mg tablets) without experiencing withdrawal symptoms from the absence of the patch?

  47. Hi, Doc.

    I’ve been using Butrans patches for several years for chronic pain, to establish a good baseline of pain relief while tackling the condition mostly with steroid injections, nerve ablation and physical therapy. I figured it was a safer alternative to taking hydrocodone or oxytocin. Meanwhile, I’ve developed Stage 4 esophageal cancer, which will be presenting its own pain challenges as my treatment goes along. Complicating matters, my insurance company no longer wishes to pay for the rather expensive Butrans patches. Whereas once the patch was a good idea, I’m now seeing it might be a good idea to just go over to the hydrocodone for now, since I’m already using hydrocodone as auxiliary to the patch. Can I just give up the patch, cold-turkey, and rely solely on hydrocodone without experiencing withdrawal symptoms from the absence of the patch?

  48. I am taking 150 mcg patches twice per day. I get a strong, almost unbearable, headache shortly after applying the film. I also feel extremely nauseous. Does it take several doses to get used to this or am I stuck with these side effects? Can I take something to counter the effects, like benadryl? I am considering stopping the patches. I always have these symptoms when taking anything that is extended release – pill or patch. I explained this to my doctor but she thought it would be different because of the delivery method. In the past I’ve always stopped taking ER meds but with this I may not have that option. Was on 75 mg of oxycodone for 5 years, knocked down to 60mg then 2 months later given this and they’re trying to get me to switch. I have not had any abuse issues, my doctor is afraid of potential lawsuits or jail due to more overdosing issues because of other patients abusing their meds.

  49. My doctor just put me in 600mcg for chronic pain. Previously, I was on Nucynta ER. The Nucynta definitely helped with my pain more. I am also on Norco for break-through pain relief.

    My question is this: Over the past 6 years I’ve been on many different Opioid medications, some very strong and some that are highly abused by many people (I’ve never taken more than prescribed).

    I noticed none of them made me feel euphoric or high (which I was glad), but it made me curious to why, or if there was something wrong with me. Other people are killing themselves to get high off these meds that to me are no different than a Tylenol.

    I’m 44 years old, and I have lived a health “clean” life. No drugs or alcohol, not even tobacco.

    Should I be concerned that I feel no affect from any medications? Is this rare? Should those like me handle pain management differently?

    Thank you,

    1. Vince, There are a number of reasons that you may not have euphoria or craving compared to another person, and also reasons why you could respond better or worse compared to another person. Euphoria from opioids is a function of how quickly the opioid enters the central nervous system. Depending on the opioid, this depends at least part on an enzyme carrier called p-glycoprotein. A similar protein is resonsible for oral absorption. Imagine if you had less pGP for absorption into the blood, or from blood to brain. Either or both of these would effect it. Then, after the opioid eneters the brain, it has to combine with a mu-receptor for analgesia and for euphoria (also respiratory depression and other effects). You could have more or less mu receptors, or the same amount but they could be less active. Then there’s the stimulation of dopamine which ultimately is responsible for the euphoria and also a cascade of negative feedback chemical reactions that cause craving – that too is genetic. This is a very simplified version, but just because dopamine isn’t as effected as someone else, or craving is not an issue, that doesn’t mean that you wouldn;t have pain relieve, because that is a separate pharmacological occurrence. Then after considering all these factors, there are others. For example, if you had more enkephalinase compared to others, the opioid would break down more rapidly after it simulated the mu receptor. And, if that isn’t enough, consider this earlier post, One Size Opioid Dose Does Not Fit All and The MEDD myth: the impact of pseudoscience on pain research and prescribing-guideline development.

    2. I’m the same way with opioids but I used to drink A lot of alcohol and also I used cocain on and off for around three years. So I’ve always thought because of my past hard living there for awhile my body has so sort of tolerance to the opioids. I think my Drs see my past substance abuse because I ended having to use the VA in order to sober up per say, and although all of that’s been well over 18 years now they still seem reluctant to prescribe opioids to me. My whole alcohol/drug problem was PTSD from serving, anyhow I’m very very glad I don’t get high from opioids because I live in a lot of pain and I actually don’t like being high or out of my mind in any form anymore.

  50. Hi Doctor,

    I am currently on 60mg a day of Oxycodone. I am switching to 10mcg/hr of a Butrans patch for chronic pain. How long after the last oxycodone dose do I have to wait before applying the patch, to avoid precipitated withdrawal?

    Thanks so much.

  51. Hi Doctor,

    I am switching from 60mg a day oxycodone to 10 mcg/hr of a butrans patch for chronic pain. How long do I have to wait after the last oxycodone dose, to apply the patch without experiencing precipitated withdrawal.

    Thanks so much!

      1. Please review the first line of your response, I think you left a word or two out. I have the same question as Carter and that’s why I’m asking.

  52. I have been on subutex for >12 years. I recently seem to have developed an allergy–EXTREME itching and skin rash. I have read that “Opioids are known to modulate the sensation of pruritus, both peripherally and centrally. Stimulation of opioid mu receptors accentuates pruritus, while stimulation of kappa receptors and blockage of mu receptors suppress pruritus.” Alas, Buprenorphine stimulates the mu receptors. What to do?? How to stimulate kappa & de-stimulate or suppress mu receptors? A drug exits Nalfurafine that does this –but its an experimental drug –for research only . Any advice? Has anyone else developed an allergic response, esp. skin rash?

  53. yes i was wanting to see if it is ok to take buccal film with sub pill? and my other question is i have been on sub strips and now i am on the pills but i got a buccal fim now to see if i wanted to switch to those and i was wondering if it is the same thing pretty much and has the same effect? and im used to cutting my sub strips in to four squares and my pills in the four also so i was wondering if i could do that with the buccaal film as well? please let me know thank you.

  54. Do I need to be wary of kissing my husbands for a few hrs after I take? I can still notice that light taste it has 2 hrs after it melts away in my cheek. (Cancer patients – we have spidy senses). I’m paranoid I’m gonna drug the hubby!!

      1. Hello Dr.

        I didn’t know where to post my question so I thought I would ask in the reply.

        My name is Jennifer and I have been on oxycdone 10mg 4-6 times a day off and on for several years. Twice I was down to 1.5 pills a day and then stressful life situations happened with my son getting cancer and now my father getting a diagnosis of ALS. I am so ready to be done and have toon the first step and saw a Dr. on the 2nd and started me on suboxone alone with counseling. The Dr started me off on way to high of a dose at 8mg twice a day. Thank god I did not take this dose. I started with 6 mg the first day. That was still way to much. So the following day I took 4 mg and again way to much. I felt so so so tired I couldn’t get out of bed and extremely foggy headed. Yesterday I tried 2 mg in the morning and 2 mg at night. It was better but still very tired. So this morning I took 1mg and 1 mg this evening. Seems much more tolerable. Still a little tired but can at least function. I don’t want to be on the suboxone long term and hoping that with counseling I can achieve this. I am a determined person and when I put my mind to something I can accomplish it. I don’t drink, never have done any other drug and never thought this would happen to me after being prescribed by my dr for back pain years ago. Have you seen people stay on the 1mg from the beginning and taper off within a 6 month period with little to no withdrawals? I truly wish that I could just quit without anything but the anxiety, restless legs, and not being able to sleep is unbateable when stopping the oxycodone even during the weening process. So again, I think the 1mg twice daily of suboxone will be hopefully all I need for a short time with counseling. Any suggestions or thoughts would be greatly appreciated.

        1. Jennifer, The way Suboxone is generally prescribed for an opioid use disorder is for your doctor to stop the full agonist opioid (in your case oxycodone), and to initiate Suboxone at the appropriate time for rescue. It sounds to me like you’ve taken things into your own hands and are doing the reverse of that; staying on oxycodone and tapering Suboxone. That will not work. You need to speak with your doctor about a strict plan.

          1. I’m sorry but it didn’t sound to me like she was saying that she was going to stay on the oxy and lower the suboxone. She simply explained that 16mgs a day of suboxone was to much for her and was asking you would using only the 2mgs of it a day not still work to help her stop the oxys.

  55. I was on 45 oxy mil every 4 hours for 5 years.. I asked the Dr to put me down cause I was tired all the time . Now I’m on oxycodone 750 every 6 hours.. the Dr wants to put me on belbuca.. is it just like Suboxone?? I know Suboxone blocks opioids. I have my 4th back surgery coming up as well as a shoulder surgery. Will being on belbuca be a good choice.

    1. Jennifer, That oxycodone dose doesn’t seem right (750mg)? Regardng your questions, the active ingredients in Suboxone and Belbuca are the same, as they both habe buprenorphine. Belbuca lacks the naloxone component which is a full opioid receptor blocker. To read more about buprenorphine and surgery, see the suggested reading on this site,
      Bettinger JJ, Fudin J, Argoff C. Buprenorphine and Surgery: What’s the Protocol? In Kean N, 2nd ed., Opioid Prescribing and Monitoring—How to Combat Opioid Abuse and Misuse Responsibly. Chap. 6. Pg. 73-78. Pub. Vertical Health, LLC. September 2017.
      Fudin J, Srivastava A, Atkinson TJ, Fudin HR. Opioids for Surgery or Acute Pain in Patients on Chronic Buprenorphine. In Aronoff G, ed., Medication Management of Chronic Pain: What you Need to Know. Trafford Publishing, 2017.

      1. I have been on Subutex for over 3 years. I take 3 a day. I have chronic conditions as well as opioid abuse history. Now a new doctor at my clinic comes in and tells me I’m taking too much….that there is a “ceiling effect”. But after reading your article it seems the ceiling effect isn’t I pain relief but the way it suppresses the respiratory system. That’s useful to know. Now she wants to take me off subutex and but me on the Belbuca. I have severe crohns disease, (that’s how my use of opioids started) I just had my 2nd major surgery for vulva cancer, and now this new doctor comes in and wants to change everything. I gave sucha very delicate balance right now. I went thru major surgery with only my subutex. And I assume she wants to change everything to make sure her paperwork is in order, but I have no knowledge of this Belbuca. Your article says it has higher buprenorphine mg dosage yet from what I see online it comesin 6mg. I take 8mg 3 times a day. And I’ve heard others speak of the ceiling effect and I can assure you that to 8mg Subutex pills does not reach a ceiling effect in its pain relief effects. Now you get up on into 4 or 6 8 milligram pills a day yeah you’re probably wasting your medicine. But I assure you there is no ceiling effect with two pills a day. And that’s what she wants me down to. I just love how the government is treating Subutex as bad as if abusing pain medication. It is changed and saved my life and now I guess due to government regulation she’s going to come in and ruin everything. Putting me on a lower dose, a new medication with lower naloxone, that may or may not even work within the 12 hours I stick it in my jaw…..I didn’t mean to get so personal I’m extremely frustrated. Naloxone gives me very bad headaches. And based on what this article says you could do without it. But I assume the government believes as long as there’s naloxone you cannot abuse it. hogwash. Ppl can abuse anything. Thank you for this article. I am researching as much as I can about Belbuca. What your article says it provides even more pain relief but I am very uncertain. This new doctor has uprooted my life by coming in and changing everything.

      1. My husband is on Suboxone strips and I am a current patient at a pain and spine specialist I’m on oxycodone 10mg. 3 times a day. I have been taking oxycodone for 2 years now and have never failed a urine screening . Last appt. I was told I tested positive for Suboxone but I have never taken it. The only conclusion I have is it is being passed through saliva when I kiss my husband , also I had gastric bypass surgery a few years back and I know that I absorb things easily and need to be careful. I am at a loss and don’t understand how or why I came up positive for suboxene but I’m freaking out here . I’ve never abused oxycodone , used more than prescribed or upped my dosage at any time . What other meds could cause a false positive or am I absorbing it into my system through saliva from him . Please help

        1. Crystal, None if this is theoretically possible. Ask your doctor to send out the sample for definitive confirmation by random liquid chromatography.

        2. Crystal, just a few months ago my husband, whose been treated for severe pain due to low back degenerative disc disease, was clobbered by his doctor’s assistant at the very end of his regular 3 month checkup. This assistant went through all the usual rhetoric you hear when there’s been no change in medication. For a couple years he had been on a pain med and he has never had any addiction problems whatsoever. He has one beer with dinner. He hates feeling woozy. Back to the last visit at that office. At the end of her usual blabbing she seemed to take great pleasure out of telling my husband that he failed his urine test and he has been barred from the practice!!! He was speechless and shocked!!! He came home in a frenzy. Ive know my husband for 40 years and we’ve been married for almost 20. I said you have to call that office manager and demand an investigation!! I talked to this manager in person. These mistakes can ruin people!! They did investigate, and the office manager said it was the first and only time they’ve had to do this. However, they did find their mistake. The lab had mixed up my husband’s results with another patient’s test!! So if you haven’t done that yet, do it now. I wish you luck!

  56. Quoted from the article “Buprenorphine is a partial agonist at the mu-opioid receptor (responsible for opioid’s euphoric effects) and as such leads to a less robust euphoric response…voila – less abuse potential! ” I’d like to find out if this is true or if one might be ‘stuck’ with another medication that is difficult to get off…. in my own case I’m having a difficult time with weaning down off buspar, effexor, morphine and hysingla, am doing it… but very very slowly even 5 mgs at a time (of each one but not at the same time of course) causes me almost unbearable anxiety…. We are all different human beings with different amounts of any given chemical(s) in our bodies that fluctuate all the time especially as our food & environment is becoming more polluted.

    I have always wondered how these opioid drugs can be manufactured and prescribed by those who have never had the fine experience of taking them and then weaning off when enough is in them to make withdrawal syndrome so that they will understand how these drugs work (in themselves) , in order to relate to patients (while knowing that no drug can be a cookie cutter solution as we all have unique body chemistry).

  57. my wife is taking 50micrograms of duragisic and was taking percoset prior to perceived opioid crisis, her doctor is going to start tapering her to the 90mme, which she has tried before and has had extreme pain. I have seen patients while doing my clinical hours go into surgery on suboxone who where unable to be completely sedated. I know one of the main compounds of subxone is buroponorpine will this also happen with butrans? Also what this the CDC’s mme doseing for burtrans?

  58. My wife suffers from chronic post-stroke pain along her entire left side. Gabapentin and opioids usually make the pain bearable. She’s been on nucynta, morphine and now hydrocodone/acetaminophen (5/325, 3x/day). Her pain doctor wants to add the Butrans patch. However our insurance doesn’t cover Butrans. (We’re waiting to see if her doctor can appeal.) Anthem will cover Belbuca. She takes 1 mg lorazepam every night to sleep, so she doesn’t take a hydro later than 5:30pm.

    What are your thoughts about taking her nighttime lorazepam while wearing the Butrans patch? (Her doctor prescribed Narcan for us to have available.) What about Belbuca and lorazepam? Could she take just one Belbuca a day in the morning, or would it be ok to take a 2nd Belbuca in the evening when she takes lorazepam?

    1. Eric, Lorazepam increases the risk of respiratory depression for all opioids. In general, buprenorphine is less of an issue for respiratory depression compared to hydrocodone, oxycodone, morphine, and other opioids commonly known as full agonist opioids. For best therapeutic benefit, Belbuca is generally dosed every 12-hours. Nothwithstanding, I cannot give medical advice on this forum – please discuss with your doctor.

      1. Dr
        Can you please explain to me why Bel Bucca or Bustrans will not show up in urinalysis. I am a bariatric patient suffering with Chronic pain from degenerative disc disease in back and neck. I have fibromyalgia, sjoegrens. and recently had total knee replacement in one of my knees. I am doing what is asked of me.Belbucca is causing my legs to swell.

        1. Queen; Opiate screen by immunoassay test generally for “opiates” of a certain chemical class, in this case “phenanthrenes”. Because buprenorphine is so potent, and requires a very low dose (microgram quantities versus milligram for most other phenanthrene opioids), as many doses, the amount in the urine is too low to be picked up on the screen. Chromatography is much more accurate and detects much lower concentrations. HERE is a list of the chemical structures – you will see that buprenorphine is in the same class as many drugs that wll be familiar to you.

          1. Buprenorphine is easily detectable with routine urine drug tests (UDT’s), as long as it is included in the panel of drugs being tested. Chromatography is used to confirm UDT results since they are notoriously inaccurate.

          2. Actually Dr. Sernaker, the lowest doses of Belbuca and Butrans may not show in urine, even with chromatography due to the cut-offs. Even serum can b van issue. All if the doses for OUD will show. Firstox offers a finger prick test that will measure the lower doses of buprenorphine.

  59. A close family member is quitting an opiote habit and is doing it with a short suboxen taper. We are wondering if Kratom can be used during that time frame from last opi use to first suboxen use.

  60. I have mainly neuropathic pain down leg and foot from nerve damage after failed back surgery, I take 90mg of morphine daily. Back feels good now and most of strength is back.(12 years post surgery). I have read buprenorphine is better for nerve pain than morphine. Is there reason to believe it is worth trying? Could the difference be significant?

    1. Jim, There’s no reason to believe that buprenorphine will work any better or any worse than morphine, but it is safer for sure. Nucynta may be a good option and might work better for nerve pain compared to either of the above due to it’s dual pharmacological mechanism.

      1. Doc.
        My wife was recently treated at pain / depression/ addiction clinic
        With Suboxone to assist with getting off 10 years of morphine and oxi for chronic pain.
        She is now down to 8 mg per day of suboxone but is leaving the pain clinic to come home.

        Still has chronic pain and needs appropriate Med which appears to be Belbuca.

        What would be an equivalent dose of Belbuca to the 8mg of Suboxone. ?

        Thank you

        1. There are no studies directly comparing the two. For frame of reference, Suboxone 8mg = 8000mcg and this is about 30% absorbed. Belbuca comes in 75, 150, 300, 450, 600, 750, and 900mcg and is about 50% absorbed.

    2. Jim, have you ever tried Gabapentin (brand name: Neurontin)? This stuff specifically treats nerve pain. I broke my back in nine places and was miserable until I found this stuff! Also, look up Lyrica (progabalin). It is a very similar medicines me, but more potent..

    3. I had an allergic reaction to Suboxone, ie…swelling, hives and trouble breathing. Will I have the same reaction to Belbuca?

    4. I love Belbuca. I have fibromyalgia x osteoarthritis, a broken hip and a broken foot. Also Lupus. I have been on norco 10 for 2.5 years. My choice. I didn’t want percocets and Oxys, I definitely broke through the norco about a year ago. But I didn’t want to go up on opiates. I finally couldn’t take it. And I decided to give Belbuca a try. It has helped me immensely. I take Belbuca, gabapenten, I ingest Cannabis and take norco for break through pain. I definitely feel like I can live a better quality life and not be in acute pain 24/7. I am on 300 of Belbuca. Start lowest you can.

      1. Lucky you! Where do you live that your pain doc lets you “ingest cannabis”. I can’t even experiment to see whether it would help with my pain.

        1. I know right. I can assure you it does but testing positive for THC on a drug screen will definitely get you expelled from any pain clinic l am aware of. Maybe Colorado or California? They have the most liberal cannabis laws.

  61. I have been taking morphine sulfate for years to help with pain caused by MS and Trigeminal Neuralgia, as well as arthritis and back pain. The TN is getting worse, I have lost 30+ lbs in the last 3months or so because I can’t eat.
    My doctor recently switched me to Belbuca. My face feels better and no side effects so far after 2 days.

    However, I feel like I am going through minor withdrawals. I went from 30 mg of morphine 2x a day to 150mcg of Belbuca 2x a day.
    My question is: does Belbuca take time to build in your system before its 100% effective? I have read some people do both doses at the same time and it helped, but I need the relief 24×7. I have tramadol for breakthrough pain, but haven’t needed it as much.
    If this continues to work, and I got a slightly higher dose, I may be able to get some of my life back. I just need to get past this withdrawal feeling to see how effective its going to be.

      1. Is this common switching from morphine to Belbuca? When the doctor suggested it I did some research and its often used for drug abuse treatment.

        I have dealt with this switching meds before, but after reading about Belbuca I really wasn’t expecting it at all.

        Also, how long does it take to be fully effective? I can tell the difference shortly after taking it, especially in my face. I am hopeful that before long it will be helping me when I wake up, before I take my morning meds

        1. Yes it is common. You should notice some benefit from Belbuca right away, but it takes about five days for blood levels to stabilize such that your pain in controlled regularly without peaks and valleys.

      2. Another follow up question…. sorry but there aren’t a lot of answers out there!!!

        I dip. Always on the right side, so I put my Belbuca on the left. Would it be more or less effective on the right??

          1. Thank you for taking the time to answer my questions. I have struggled finding answers online but I got most of my questions answered by just reading through the other questions and answers.

            I have to have Sphenal Palatine (sp) nerve blocks 2x a month. I am hopeful that the Belbuca will allow me more time between, and more relief. Plus not having opioid side effects will help me regain my life, or at least some of it

  62. Very informative blog. I have been on morphine for 6 years, post-op, and was on Tramadol for several years before my surgery. My back is a mess and there is nothing left but to remove the hardware and treat the pain. I started with 300mg as 3-60mgER plus 4-30mgIR morphine. I was on that dose for 6 years. Today my pain doctor asked if I would try Belbuca. I have tried what seems like everything else, from the surgery to Oxys, etc. and all of them only had minimal pain relief for me. I have had every kind of injections, nerve blocks, and finally a spinal cord stimulator. The stimulator worked, but I needed it set on a high setting to mask my pain. I was approved for the implant, but then found out my portion of the bill would be $4700, just for the hospital and surgical suite, not to mention the doctor, anesthetist, nurses, radiology, etc. I’m totally disabled and , unfortunately, of limited means, so it was not to be. In the old days they would treat patients first and then discuss how much it costs, but they would not even check me in without the $4700, up front. I’m assuming because they are dealing with patients that are probably like me and didn’t, or couldn’t pay in the past. To tell the truth, I wouldn’t be able to pay either. At least not in the near future. My life has been taken from me by pain, not the doctors or the initial injury. It may be helpful to explain that my surgeon took me off Tramadol because IT WORKED TO WELL!!! I understand that after the surgery, the pain was complicated and required some trial and error, with the error being severe chronic pain post-op. I have not had a pain level below 3 or 4 since the surgery, and granted that’s a lot of relief for most, including me. I have learned to trust my pain doctor, but not because he hasn’t tried stuff that didn’t work at all, but because he BELIEVED I was in pain. I never was early, or did any of the “drug seeking” behaviors, other than request a larger dose when it wasn’t working. I have a belief that I deserve the pain I have because I did something stupid and injured myself. I don’t blame him or anyone else for what I did. If I can have a life of anywhere below 5 on the pain scale for a part of the day, I’m happy. My newest dose changed from 300mg/day to now 180mg/day due mostly to modifying the dose so I wasn’t “impaired”. to much to enjoy life. I appreciate my pain doctor, and because he has been up front with me , I feel like I can be up front with him and he will not only listen, but explain why he thought a dose was too this or too little of that. He is treating my pain, and sometimes it is UNPLEASANT, but I know that as long as I am honest with him, he can figure this out for me. Sure, I think this reduced dose is too little, but only because I have been on such a high dose before and could let the drugs do the work of healing for me. It doesn’t work for me to NOT have a “little reminder” that my back is screwed up and I shouldn’t be stupid again and injure myself further. It sometimes feels like a little pain is good; not because it feels good, but because I am that much farther from needing something that makes you drool and slur your speech. I kinda know it will eventually get there with me, but not today. We are trying Belbuca and tomorrow I start on 450mcX2, and we will see how its going to work. He told me it works a little different, but he has had good feedback from his patients like me. He gave me my regular prescriptions and asked me to try it without the ER doses but to discontinue it if I feel I can’t get some quality time with “my little friend” to go back on the ER as soon as I feel I’ve given it a chance to work. The fact that my pain doctor trusts me is because of my BEHAVIOR, not because I DESERVE some special consideration or care. I am blessed in this regard, but sadly, most of the things that were my life are over. I can’t ski with my grandkids anymore, or go fly fishing the Yellowstone or hike the Grand Canyon, or do much more than just try to find what happiness I can with the new me. My pain is my burden to bear, not his. I really hope this drug works better than the spiral of opioids has become, but if not, so be it. At least I know my pain doctor is in the fight with me, and that is the best outcome that I deserve; the rest is gravy. Thanks for being here to let us share our experiences with this sentence that is pain. Jeff

  63. I’ve been on opiate pain meds for 7-8 years after multiple spinal surgeries (5) as the result of a bad accident and I have degenerative disc disease and arthritis. Other than directly after surgery I have maintained between 20mg hydrocodone 3 times a day to 20mg oxycodone 3 times a day. This was done by titrating and increasing my dosage every few months, keeping my body from developing too much of a tolerance. This has worked to control my pain just fine for these last 7-8 years. I had to switch pain management doctors a year ago, after moving from one state to another, and now my doc has been pushing long acting meds, hard. Dilaudid was so strong I felt like a zombie. Stopped that after a month and suffered severe withdrawals. Morphine ER did nothing, whatsoever. Xtampza made me violently ill. Stopped that garbage. Now they’ve told me I need to add Belbuca to my current dosage of 15mg oxycodone 3 times a day.

    My question here is, obviously having some adverse reactions to long-acting medicines and my doctor not dropping my current dosage slightly because of the addition of a new medication, am I at risk to become sick, yet again? Additionally, will the 75mcg dose of Belbuca twice a day make my dose of oxycodone not work? Between my multiple surgeries and 6-7 years or so of doctors keeping me on the previously mentioned system, always intended to keep my dose as low as possible, is this even going to help or just lower the relief I’m getting?

    1. This is generally not the proper way to titrate Belbuca and it is inconsistent with the FDA-approved package insert. It make or may not make you sick. In general, as buprenorphine is introduced, the full agonist opioid such as oxycodone should be tapered downward. This is something you need to discuss in detail with your doctor because not all patients react the same way.

      1. Short history-8 back/neck surgeries, Trimalleor ankle fx with 13 pins 2 plates placed.
        Taking Norco 10/325 TID for years. PM Dr began Belbuca 150mcg last week and said Norco for breakthrough pain. My question- what is timeline between taking Belbuca and Norco? I had terrible pain 3 hours before I was due for next Belbuca, I was scared to take that close together.
        Would it have been ok to take the Norco 10/325 that close to next dose of Belbuca?

        1. Lori, You need to discuss this with the person that prescribed the medications and figure out what the intent was. Generally speaking Belbuca is dosed every 12 hours, and the Norco as needed is generally prescribed up to 4-times per day in divided doses. The proximity to the last Belbuca dose does factor in. Expect that it takes about 3-hours to reach peak levels of Belbuca, so I suspect your doctor would want you to wait at lest that long prior to taking a breakthrough medication.

          1. I’m a chronic pain sufferer and have been placed on disability (even though I chose to retire at age 62 due to pain). Anyway, my doctor gave me Butrans patch and also gave me Vicodin for breakthrough. What I don’t get is if Subutex blocks the Vicodin from working, then why give it to me? Doesn’t make sense and wondering if I need a new doctor. 😉

          2. Butrans and Sebutex are two different things, although they both the same active ingredient. At the highest of Butrans doses available in the US, there will be some unoccupied binding sites for hydrocodone to bind with, albeit reduced while on buprenorphine compared to other traditional opioids. So this regimen could be beneficial.

  64. My research notes that buprenorphine was introduced in the 1970’s for treatment of pain. As the drug was use it was noticed that it had other benefits but pain was what it’s original use was for.

  65. Hello Dr ….NEED ADVICE PLEASE ON A 20 YEARS JOURNEY THROUGH CHRONIC BACK PAIN

    I have a question about Belbuca. I have chronic back pain and was diagnosed with Ankolysis spondalytis last year so I am now on Humira bi weekly. I have been on pain medication for chronic and severe muscles spams. Over the past 15 years we have tried everything, the current meds are hydrocodone 10mg x 4 day and 3 soma a day. My GI tract has been very bad lately, chronic constipation, severe bloating, so they did a colonscopy, endoscopy, MRI, etc. The only diagnosis is constipation – caused by years of opiods. Hydrocodone and soma aren’t really touching the pain so I feel like I am on it just so I don’t go through withdrawls so I talked to my pain doc this week and she suggested BELBUCA. She started me at 75 mcg x 2 day. After a week we will discuss if I need to go up. She told me that because Belbuca binds so strongly to the opiod receptors, that I could essentially just STOP my hydrocodone right now??? THat’s a scary thought as I have gone through serious withdrawl years ago when I stopped suddenly. Also, I am seeing that Belbuca stays in the system longer , 30 plus hours? If so, why do we need to take twice a day, can’t that cause potential overdose? Also, if I am taking 4 hydrocodone and that’s not doing too much right now, how does the belbuca compare? I am only 41 and have 2 young kids. I am sickly all the time, my auto immune disease AS is a constant level of inflammation which makes by back so much worse. Nothing seems to be helping….Plus my constipation was very so bad, in your opinion is belbuca better to reduce constipation and how about chronic constant pain? Do I really just STOP hydrocodone??? Doesn’t seem like 75 mcg will be enough if hydrocodone and oxy don’t touch it?

    1. Gina, Here are the answers to your questions with some comments.
      1. If Soma isn’t doing anything, you should be tapered from that ASAP because it’s a very dangerous drug to be taking with opioids (especially hydrocodone or other similar ones), as Soma is metabolized to a potent tranquilizer called meprobamate. It’s important to note that this needs to be tapered slowly because abruptly stopping it will cause withdrawal
      2. Clearly, while you’re on Soma, Belbuca is many times safer than combining Soma with hydrocodone. The reason is that hydrocodone and Soma combined have a very high risk of respiratory depression. With Belbuca, there is a ceiling effect on respiratory depression, so compared to traditional opioids it is generally safer.
      3. If you have unresolved opioid-induced constipation, there are a number of drugs that specifically target the gastrointestinal tract at the site that opioids cause constipation in order to prevent it – they are all very effective and collectively it’s a group of drugs called PAMORAs (peripherally acting mu receptor opioid antagonists). Examples are Methylnaltrexone (Relistor), Naloxegol (Movantik), and Naldemedine (Symproic). Also posted a blog on this this in 2014 before all three were on the market, at https://paindr.com/overview-and-novel-therapies-for-opioid-induced-constipation/. If you remain on hydrocodone, and constipation is a huge issue, one of these would be very appropriate.
      4. Belbuca would probably have a profound effect on minimizing or even elimination opioid-induced constipation.
      5. It is fine to abruptly change over from hydrocodone 40mg per day to Belbuca, but the dose of Belbuca your doctor prescribed may be too low, and while it will bind tightly to the receptors and provide adequate, and perhaps superior analgesia compared to hydrocodone, you may experience some withdrawal, not because it’s less effective than hydrocodone. Instead, it’s because the dose may be too low. It is possible that at a higher dose you’ll have very minimal withdrawal too, but for a different reason. At higher doses, Belbuca will actually displace hydrocodone from the site of action, but the dose of hydrocodone is too low now to cause massive withdrawal if replaced with Belbuca – some mild to moderate withdrawal at most. I know this all probably seems complicated, and it is because Belbuca has complex pharmacology. Suffice it to say, you should discuss your concerns with your doctor and if you have a great relationship, feel free to print this off and bring it along. This chapter, at https://paindr.com/wp-content/uploads/2018/02/2017-chapter_Buprenorphine-and-Surgery-Whats-the-Protocol.pdf, is a bit complex, but will help you to understand the withdrawal issues.
      6. Taking Belbuca twice daily is consistent with the FDA labeling. Yes, it has a very long half-life, but half-life is a function of the number of hours for the drug to reach half the blood concentration. In other words, if the blood level of a drug is 100ng/mL, and in 4-hours i decreases to 50ng/mL, the half-life is 4-hours. The reason it’s doses twice a day is so that the blood levels stay within a therapeutic range between doses.

      1. Hi Dr. I can’t seem to find an answer to my question, hopefully you can help. I have 50-75% fibrosis of the liver and chronic diarrhea even though I’m taking 30mg morphine sulfate and 10mg oxycodone 4xdaily. I don’t believe my body is metabolizing these medications correctly because of these medical conditions. Will the Belbuca work for me? I have severe degenerative disc disease though out my spine, RA, OA, CPPD and also 38 degree scoliosis of the lumbar.

  66. I am a 42 year old female with several chronic pain issues. I don’t tolerate traditional opioids well and decided to try the Butran Patch with my doctors guidance at 20mcg’s. I have a few questions that I am desperate to figure out. First, I was on 45 mg of Methadone for pain and had horrible weight gain and just too many side effects. I was taken down over 5 days and then put on my Butran Patch. I feel horrible. No energy to even get out of bed and so weak. My legs feel like jello. Is there anything I can do? Second, the pain relief has been a challenge but I have only been on this patch for 4 days. Will that get better?

    1. Christina,

      There are two issues at play here. First, the comparative Butrans dose is lower than the methadone dose. There could be some methadone withdrawal symptoms when placing the Butrans on for the first day or two. As the week goes on and methadone levels drop, there would be more withdrawal not due to Butrans blockade of methadone, but because the methadone was abruptly stopped. You may start to feel better after 1-2 weeks. But, my sense is that you may require buprenorphine in a form called Belbuca, because the achievable dosing options and commensurate buprenorphine blood levels are higher.

  67. Last couple of questions to set my mind at ease and accept Belbuca is my main medication with lyrica for at least the next ten years or so , please indulge me if you will :

    1) is it true that bupeprenorphine causes long term damage to brain (synaptic misfiring, death of cells or dulling of neurons causing decline in all faculties and cognition ) ??? If so, in what doses are these types of damage resulting from over prolonged exposure or abuse of Belbuca ?

    2) is twice a day dosing needed? It seems the medication half life or metabolites can last 24 hours or so… is it possible to take let’s say one 600mcg film instead of two 300/450mcg in 24 hrs?

    I wanted to know because the let’s meds the better, but if 12 hr twice daily is needed for optimal effect or plasma levels that’s fine

    You can be as technical as you like, doc… Stephen stahl is my reference guide and teacher lol

  68. Dear dr

    I was on 15mg TID (45mg daily total) after my acute injury, and then 10mg TID as maintenance… I wanted to get off Roxi on my own volition to switch to a drug with a safer profile (I just had my first child at time) and so now I’m on 450mcg of Belbuca

    (1) Is this an accurate conversion dose??

    (2) Also, how does SO little (microgram ) of bupreorphine manage what took arguably such a high daily regimen of Roxy?

    Thanks

    1. Cris,

      The equivalent isn’t exact but that seems reasonable. The microgram dose compared to milligrams is nothing to worry about. Buprenorphine is more potent, so you need less of it for the same effect.

      1. If I take 5 mg’s of vicodin and have been on 16 mg’s of suboxone for a year and a half. How many vicodins do i have to take in order to push through the suboxone?

          1. Well actually, buprenorphine is not blocked by naloxone because buprenorphine has a higher binding affinity to the receptor than naloxone does. In the scientific world it’s measured by ki binding, and the lower the number, the better the binding.

  69. Do you have any general sense of going from morphine to butrans for chronic nerve pain from failed back surgery? Can it be at least as good with hopefully less side effects? I take 90mg morphine per day and have nerve pain down leg and foot for 10 year.

  70. This belbuca is no good just another drug your pharmaceutical companies formulated my wife was in a bad car accident can’t get no pain medications but give her these which cause sores blistering in the mouth I’m just telling you now all your doctors need to get a grip on this life sick of your mumbo-jumbo wording and it means nothing

    1. Absolute lies….you obviously got belbuca INSTEAD of your oxy and you are pissed because you either didn’t get high because your abuse is so bad OR you put 5 in your mouth at once, and none of them stuck

      STOP DOING DRUGS BRO

    2. I Agree!
      I was really excited to try
      I started on 150
      Then 300
      Now 450
      I’m unable to feel any relief At All
      I’m going to try for one more month
      And I hope it works
      The strips are very expensive to not work!
      They are a Joke
      And i really wanted them to work!

  71. I have searched and searched and can’t seem to find an answer to this question so I’m hoping maybe someone here can answer it.

    I was put on the BuTrans patch Friday for chronic pain. Mind you, I do not meet any of the prescribing guidelines but my new Dr swears by it and it’s the only thing he’ll prescribe someone under 40 for Chronic pain. I had been on Ultram for 6yrs until my Dr retired in March of this year. I was pain medication free for 6 months before being put on BuTrans (that’s how long it took the new Dr to decide if I was worthy of treatment). When I was on Ultram it didn’t make me groggy, high, euphoric, none of that. It just relieved my pain.
    *Now with the BuTrans I have no energy at all, I’m groggy feeling, lacking motivation completely, and I’m still having to take a high dose of Ibuprofen (800mg every 6hrs) to keep my pain levels functional (that’s what I had to do in the 6mo as well).
    Will this complete lack of energy and motivation go away with time or is it only going to get worse? What can I do to get my energy level back?* I’ve only had the patch (5mcg) on since Friday and if this is what being on BuTrans is going to be like, it’s not going to work for me. I have a lot of responsiblities and it’s bad enough having pain that limits my activity levels at times, but to have absolutely no drive to do anything since waking up Saturday with very minimal results I can’t have happening.

      1. Dr Fudin
        In your opinion, while starting on the belbuca (lower dose). Which break through medication will have the most effect, hitting the left over partial receptors.
        Also rarely discussed is that many opioid pain relievers provide a two part response, one being to relieve your pain the other is a mood enhancer. I think the chronic pain tends to make us all angry and unproductive, so aside from just relieving pain it’s nice to also improve our happiness. So this part of pain relief is a huge plus , when you now will play ball with your kid or clean the garage or feel productive.
        I hope you will respond. Thx Scott.

      2. Dr can you elaborate on that?

        Do you mean there is a perhaps mood elevation for “refractory”, treatment resistant type depression

        I ask because I have PTSD along with my chronic pain/neuropathy and I wanted to know IF there was dosage of belbuca that might be able to achieve OFFlabel relief for my PTSD related depression and anxiety, as some studies do suggest (that certain opioid can also treat depression)

        If so, what does would be needed,? I am assuming over 450mcg because of the elevation/agonist effect?

        Please discuss

    1. I’ve been o Subutex, 32mg daily…I have degenerate disc disease…I was given oxycodone 30 mg 3 times daily…. didn’t do shit & that’s after 7 days off sub
      It takes up 2 3 weeks until I got pain relief… also had withdraw… Subutex overfills pain receptors…oh good luck getting a Dr to give u any opiate..

    2. It sounds to me like you may be on too low of a dose of the Butrans or it may not be the right medication for you. I would go back to that doctor or go to a new one. You shouldn’t have such a hard time getting tramadol, it is the weakest pain med they can prescribe! Good luck

  72. I have been taking Belbuca for just under two years. I had been prescribed Percocet for a ruptured disc and had trouble stopping. I was clean for over 17 years. My max dosage was 450 mcg 2X daily. I had weaned to 112 mcg 1X daily. Now I am on 75mcg 1X daily. My question is do I continue to wean? At what point do I stop?

    1. I’m interested in a reply to this as well

      Same dosages and I want to titration down to wean off

      I want to know the same thing Bobby is asking:

      Once you get to 75mcg once a day, when do you stop taking it?

      I would assume 75mcg every other day for a couple of weeks, followed by another couple of weeks of 75mcg PRN while you discontinue?

      Ideally, weaning off a heavy duty opioid is done in a medical setting under close supervision of a medical care professional, but obviously in this digital age, NONE of us are on here to do that (joke)

      Dr. Jeff, please do chime in and let us know what you think is a safe discontinuation window as outlined

      Thanks

      1. Once a patient is down to Belbuca 75mcg per day, as long as there are no other opioids being used, it can generally be stopped with no futher taper. Although it’s not 100%, if there are even withdrawal symptoms at that does, they should be minimal and tolerable.

  73. I have had 10 back surgeries (4 cervical and 6 lumbar) and for the past 23 years I have been on MS Contin, 60mg (2x’s daily) and Tramadol, 50mg (2 tablets 2x’s daily) for break through pain. I have never needed an increase in my medications, resulting from tolerance or no longer providing me adaquare relief. These medications have helped me significantly and provided me with a quality of life and allowed me to maintain an active and successful career.

    Recently, my pain management doctor has suggested that he would like for me to start taking Belbuca in place of MS Contin and Tramadol. How long will it take me to come off these opiods after being on them for 23 years? Also, will Belbuca provide me the same pain relief?

    1. Tommy,

      There’s no way of knowing if Belbuca will work as well as the combination of tramadol plus MSContin. But tramadol will offer to opioid benefit in the presence of either morphine or Belbuca. Tramadol works generally as a very weak opioid, but also increases norephinephrine and serotonin intra-neuronally. It is the norepinephrine portion that is helpful for pain. Therefore, while Belbuca may be able to replace the MSContin, it would probably be beneficial to be on a drug like duloxetine to replace the tramadol. How long the taper takes really is very patient specific and therefore I cannot predict if it will work or how long the taper will take.

      1. Jeff,

        I appreciate you taking time to respond. I will discuss with my pain management physician the possibility of including Duloxetine along with Belbuca.

        Tommy

      2. Hi Mr. Jeff … I had been on zubsolv 8.6mg twice daily for 3 months until I moved to a new state and found a new Doctor. I told the Doctor I wanted to continue my Zubsolv treatment and he said he was writing a generic but it would be the same medicine. Well he wrote me Buprenorphine 8mg SL . He is the doctor so I assumed and trusted my medication would be the same … The pharmacy said they couldn’t fill it without speaking with the doctor first. Which I figured was no big deal. Maybe it was because he was a new doctor and I was in a new state. However once I picked up the prescription I seen it was pills in a pill bottle. Never seen them before and I told the doctor I couldn’t bare the pill form of Suboxone tablets and I’d get sick with headaches etc. So why did I just get these pills? What are they? The answer is Subutex. Why would he give me a different medicine than I previously was on? Now here I am,just seen him for the second time and he wrote me the film’s. Well my insurance wants a PA done. Idk what to do now? I can’t afford to buy the strips. This is the second month second different medicine and I was doing great on zubsolv.

      3. Jefferey Fudin While on Belbuca can breakthrough pain meds be taken? Im on subutex for chronic pain. Its not covering my pain. I’m not an addict I’m a pain patient. I was on regular pain meds 15 years same dose. I had quality of life. Now I’m a shell of the person I wonce was. Is it true with subutex less is more? What is the difference in subutex and Belbuca?

      4. I can’t figure out how to post on here so I am using this reply.
        I am weaning down from 7 oxy 30s a day to 4 oxy 30s a day and the buprenorphin film. Originally my doctor was just going to wean me off the oxy all together and just go with the film. My last visit I told him I was concerned about emergency surgery and Qt longation because I had to come off off methadone for that.
        After I told him that he said the new plan was to put me on the bulbuca film once I was weaned down to 4 oxys. I asked him if it was ok to take short acting with that medication and he said it would be fine. He does plan to continue to lower my dose until he feels my dose us ok I guess.
        I have to see another doctor for the bulbuca film since my doctor isn’t that knowledgeable on it. Now I am wondering if I can take both medications at the same time. I haven’t read anyone else taking both. I am curious if you have ant thoughts about this.

      5. My doctor claims I can still take oxycodone with the bulbuca film to treat my pain. Does this sound right? I haven’t read other people continuing to take a short acting medication with it except in specific situations for a short time.

          1. Every available dose exhibits agonist properties from 75mcg twice daily up to 900mcg twice daily, and likely doses beyond that which for Belbuca have not been submitted to FDA for approval.

    2. I’m sorry to say that Belbuca will not provide the same level of pain relief. I’ve been taking it for yrs and although it takes the edge off it does not help with sever pain. Even if you take higher doses there is a ceiling, it stops at a point and does not help to take more of it.
      If your current meds are working and not effecting you mentally or physically then you should stick with them. Once they take you off, it will be nearly impossible to get those pain meds back due to the current prescription drug abuse epidemic in our country. It’s unfortunately taking pain meds away from people that truly need them.
      Good luck, I hope this helps.

    3. Yes! I was Leary if changing myself. I’ve had two back surgeries and have chronic pain. The belbucca gives you your life back. I can take Percocet for breakthrough pain, but it doesn’t give you the euphoric effect. Almost compared to taking an aspirin. I wish you pain relief in your journey. Don’t be scared. Go for it.

    4. For what it’s worth, I’ve been on hydrocodone (tried Nucynta- good relief but terrible mood swings) for a herniated disc for 7 years. I had moved to 80 mg Hysingla time release for the past 12 months or so. Dr suggested I try Belbuca because it’s not as highly regulated and would save me the monthly visit to his office for refills if it worked. He did warn me of possible wd symptoms in the transition and there were some- MINOR hot flashes, cold sweats, and an “off” feeling for about 3 days. Had to go from 450 to 600 mcg after the first two weeks to level the noticeable drop around 10 hours in. Now in week 4 all is good. It’s not quite the same relief as the 24-hr Hysingla but it’s damn close and gets me off that “watch list” for potential opioid abusers that forces everyone- at least here in NY- to go to the PM office each and every month for their refill. If the Belbuca fails in the future to do its job I’ll certainly come back and post that but for now, for my .02 I’d take your Dr’s advice and try it out. You can always go back and the crossover isn’t anything to be afraid of based on my experience.

      1. I’m confused about your comment stating that you do not need to see your Pain Management Dr monthly for your Belbuca RX. Belbuca is also controlled and requires a monthly visit for a new RX. No refills permitted. Has this changed? I just saw the DR yesterday and am currently waiting for the usual run-around trying to fill my RX. I have been on Belbuca for cervical and lumbar issues for 6 months as I can’t stand the side effects of hydrocodone.

        1. Schedule II Controlled substances may not be refilled. Belbuca is a Schedule III and as such can be refilled according to federal regulation. The same is true for other buprenorphine products and also codeine combined with acetaminophen, aspirin, or ibuprofen.

  74. Hi Dr. My father in law who is 58 takes suboxone to wean out opiate cuz it was not helping his chronic back pain. Question is his Doctor recommended him start on 15mg butran. Will he get precipitated withdrawal when he goes back on suboxone after getting off butran? I have read stories about P.W. but couldn’t find between suboxone and butrans. I guess they dont since both are made of buprenorphine?

    Thanks Tim

    1. Going from Butrans to any dose of Suboxone shouldn’t cause withdrawal because the highest dose of Butrans is less than the lowest dose of Suboxone in terms of total buprenorphine.

      1. Can you go from suboxone to butran ok ! Without withdrawals?? You said that suboxone is stronger than Butran. “Highest dose of butran is lower than the lowest of Suboxone

  75. Hello my son is 14, has ehlers-Danlos that greatly affects his spine and mainly his cervical spine. He is in severe pain 24/7. He was on 15mg morphine q4 hours day unti he was changed to the butrans patch 5mg almost 4 weeks ago. He says it does not help His pain at all and is making him terribly nauseated. He has barely eaten anything in 4 weeks and lost almost 20lbs. We have talked to his Dr. he just says hang in there until he adjusts to the patch, however he’s not adjusting. He has zofran and compazine and they are nothing not helping plus he has abdominal
    Pain. Is this a normal reaction? Will it start to help his pain at some point? Thank you

      1. Dr. Funding I can’t find help. I have been on Subutex 10 years and am miserable. What can you suggest. All they give me are antidepressants which I stop because they don’t have a well being affect. Please give me advice. Thank you.

        1. I suggest you see a psychiatrist that is familiar with genetic testing. Ask him her her to evaluate your genetic profile. If your lacking MTHFR or have a COMT polymorphism, treating your depression might require a different approach.

    1. I am a 52yo female who also suffers from ehlers Danlos type 3. I was missed dx at age 12 saying it was rheumatoid arthritis. I suffer greatly as am sure ur son does. With this “opioid epidemic” the meds I was on (dilaudid and fentynal) are no more an option at the dosages I was on. My new Dr just prescribed belbuca that dissolves on the inside of cheek. Has your son ever tried this before? If so wondering how it was for him vs the patch. Don’t know your experience with drs, but most have been me educating them!! Any advice or help with this devastating dx would be wonderful. I will keep u in my prayers. God bless! Kim

  76. Help please,

    I know you’re busy so thank you in advance. I was on 75mcg of fentanyl but have gone down to 37mcg because my dr wants me on belbuca. He wont switch me over until I am on 25mcg but I have been on 37 for a month and I am in alot of pain. Can I switch from 37mcg fentanyl to belbuca? Dr says he has tried in the past from a higher fent dosage but it was too hard to gauge how quickly to ramp up

    Thank you for any advice

      1. I need help please. I had the above question. My dr decided to put me on belbuca while I was still on 37mcg of fentanyl. I was leaving to go out of town so at the last minute we changed the script to buprenorphine because dr thought insurance might approve generic quicker.
        Dr gave me 2 mcg every 6 hours and asked me to try and drop the 12mcg fentanyl but could keep the 25mcg on. I did
        Now that I am home dr got approval for belbuca . Picked it up tonight and it’s the film 600mcg + still on fentanyl 25mcg the 600 seems high to me . Is 2mcg buprenorphine sublingual equivalent to 600mcg film? Please help going to yellowstone in 2 days and want to get this figured out before I leave

        Thank you so much

          1. I have had 3 failed lumbar surgeries and was taking 40 mg OxyContin twice daily and 15 mg oxycodone 3 time daily for breakthrough for the last 14 years. Never missed a pill count or urine drug screen. Since I live in the Appalachian opioid epidemic he started switching all patients to Suboxone so I trusted him and have no relief after 6 months. I did experience some withdrawals but I fought through it and now I’m not so sure I should have went along with it due to very minimal pain relief. I understand the active drug in Suboxone and Belbuca is buprenorphine but am wondering if Belbuca doses are higher than the Suboxone 8/2mg I’m presently taking.
            Thank you in advance

  77. Thank you. Very helpful and informative. I have had my neck broken twice. I have had 2 surgeries and suffer chronic pain and tremor on the right side. I take Belbuca 750 mcg and the nausea is hell. I am on Zofran x2 day to help. I am happy though to be off of Morphine 45 mg x2 day. The morphine was killing me. Suboxone was a joke, I sweat it off constantly, and woul find it stuck to my bed sheets, it my hair, on the floor etc. It’s too small to keep up with, therefore did not help with pain at all. I’ve been on Butrans before. I was always bed ridden on day 3 and never understood why. Your information was informative as I now have a better understanding. I am on Belbuca and Oxycodone 10 mg x3 to 4x per day. I am very happy with the results. The Belbuca is a little strong therefore I have not moved up to a higher dose. My pain level is about a 2. This is the best pain management I have had since 2012 when I started pain management. Other than the nausea, Belbuca is an answer to prayers.

  78. I have previously been on 15 mg oxy 6 times per day plus 50 mcg Fentanil patch. My doctor has converted me to Subutex for pain management and prescribed 1 1/2 8mg pill per day. I am still having quite a lot of pain. Is this the right Subutex dosage to replace what I was previously taking?

    Thanks

  79. I have a quick question. If your drug is changed from subutex, to suboxone, can you fill the suboxone 25 days into the subutex script, if discontinuing subutex?

  80. Dr. Fudin,

    Please tell me a little bit more about the interaction of buprenorphine and Nucynta.
    I am a 24/7 caregiver for my friend who has suffered from intractable pain from interstitial cystitis for 30 years. For most of this time she was on very high dose morphine. A year ago she had to get a new pain specialist. He converted her to buprenorphine only at first. Her response was very promising at first but now she seems to get little or no pain relief at all. Nucynta was subsequently added also with little effect. The doses titrated upward over the last year still with little effect. She’s now on Suboxone SL 12mg/3mg film with the buprenorphine dose at 16mg (1-1/3 films) BID and Nucynta 100mg 5/day. Some of your previous posts hinted at buprenorphine’s blocking effect being dose related. My friend in now on the max dose of both meds.Can or should they be effective at these doses or is Nucynta’s opiod effect being blocked?

    1. Todd,
      The dose of buprenorphine is pretty high compared to buprenorphine products that are FDA approved to treat pain (Belbuca and Butrans). But, there still will be some unoccupied opioid receptors that can be filled with tapentadol. Nevertheless, because tapentadol doesn’t have the same binding affinity as certain other opioids, there certainly will be competition at the receptor binding sites that will lower the activity of tapentadol. Tapentadol also has pain-relieving activity because it blocks reuptake of norepinephrine, which is a very unique attribute of tapentadol. You may want to print this out and give it to your friend so that she can discuss various options with her doctor.

      1. Hi I am 32 years old. I as well suffer from interstitial cystitis as well as endometriosis. I was originally taking norco 7.5 and morphine 20mg 3x daily. Then was moved to methadone and norco 3x daily. After so long nothing helped. I started seeing a new doctor for my pain. He tried suboxone 2mg-0.5 – 8mg-1.5 and oxycodone 2-4 times daily as needed. I was still getting very mild relief from my pain. I was very disappointed I hoped for a better outcome. Now he wants me to try belbuca 300ms. My insurance needed a prior authorization? First question what is that,? And second question is this type of medication help with my type of pain? I haven’t started or received it yet waiting on the authorization ? Please and thank you for your help.

        1. Melisha, I cannot predict how you will response. But, Belbuca is buprenorphine, the same active drug found in Suboxone. Belbuca is a small patch (film) that is applied against your cheek and it dissolves within 30 minutes. It generally requires every 12-hour dosing.

        2. Melisha, I have IC and endometriosis as well. Have you tried Elavil for your pelvic pain? I take oxycodone for this and other pain and am considering a switch to Belbuca as well, but for that pain, the Elavil has helped the most. If you need to talk to someone in the same boat or have questions about meds or what may/may not work, feel free to write me at herronml@gmail.com. I hope you find something that helps soon.

  81. I am on subutex 8mg x 2 a day. I was in w/d for 8 months because a went to a new dr..and I told him I have been on 3 8mgx a day..he said I only give 2 take it or leave it. So I took it. Ever since I felt like wD he said NO..So I decided to find a new doc and she is fresh out of college..the best dr. Visit I have ever had in my life she is also a psychiatrist just like all m6docs since 2007..on subutex..so she told me I possibly need 3 to 4 8mg a day..told me to play around a bit with the dosage and come back in a week..its still not working I cannot believe it before they went generic I had no problems..I want to ask her about the belbuca .I’m hopeful that will work. Any feedback would be great thank you so much for your time

    1. 3 ro 4. 8mg buprenorphine is alot! I’ve been on buprenorphine (Buvinail) for 9 years. I have major pain issues also from multiple orthopedic surgeries and a past spiral burst fracture.of T10 T11 T12 vertibreas. I bounce from 8mg a day to 16mg a day every 6 months or so and lower doses seem to treat pain better than higher. Now, I’m not a doctor but all I see in these.kinds of online things is doctors who do their best at giving us info on this drug, but.just go by.what they hear.from us and manufacturers. If your doctor has you on more than 2, 8mg suboxone (buprenorphine) I really would check that doctors motives for that. I know hardcore IV heroine addicts that do fine on 8mg to 16mg. Not only is it expensive.as hell, you have to be having headaches or something. If I took that much it wouldn’t be good. The fact is that the information that the.healthcare provider has isn’t 100% acurate alot of the time, not on purpose, but they just don’t get taught the facts of the medicine. Always research what your going to take and get more than one opinion. I just wanted to give out some info that ive.learned in almost 10 years of its use. I have studied it’s effects alot. Hope this helps.

  82. Dear Mr. Fudin,

    I’ve got a question for you. I’ve been on the 10mg Butans patch for six months, and it has worked well in addition to my spinal cord stimulator and various exercises and stretches that I do daily (Let’s just say that my spine is busted, to put it mildly). If I were to take any medication for breakthrough pain (days six and seven of wearing the patch are painful days; it becomes much less effective toward the end of its use), would it work? Or would the buprenorphine block that medication from working? (Example: hydrocodone 7.5mg is what my pain management doctor suggested). I am hesitant to start taking this, as I have experienced its negative effects before. Would this breakthrough pain med work, or is it not even worth taking? Just wondered what your opinion would be…obviously I’ve discussed this with my doctor and will be doing so again after I hear your answer. Thank you so much for your time and for helping those of us with chronic pain whose lives are miserable without these medications. People without chronic pain just don’t understand. Any advice you could give would be greatly appreciated. Thanks again.

    1. Allison, Speak to your doctor, but it should work. The Butrans dose is low enough that there will be unoccupied opiate receptors to be uptaken by the hydrocodone, especially on the last days before patch change. But, your doctor must be ware of this – it is not something to do without his/her prescription or advice.

  83. I’m on subutex to avoid opioid withdrawal while pregnant, but it’s not helping with my headaches and I can’t take anything with Tylenol. Would I get sick if I took an oxycodone while on the subutex. I know it probably won’t help much with the headache, with the subutex blocking some of the pain receptors, but even if it helps a lil I’ll take it. I just want to make sure it doesn’t make me sick or send me into precipitated withdrawal like I think it does with the suboxone.

    1. Super selfish. Not what will happen to my baby or is it safe for him? No just i want to get high again so my headache goes away. You make me sick . The oxi will not work and you wont feel it all . So you will take more . Then your baby will likley overdose and die because you wanted to rid yourself of a headache. Dont do it . It will be uncomfortable but stick it out for your kid. Do the right thing

      1. Very judgmental for someone who has no idea her story. .. Throwing stones is makes a shirty personal all the time.hands down.

      2. You said what i was thinking. I didn’t hear anything about her baby just her headache. I have a friend who is four months pregnant and still eats i would say 10 mgs oxy 4 times a day just so she isn’t pill sick. I refuse to give her any kind of opiates. Don’t women think about what they’re doing to their unborn child. I don’t get it. Anyway great comment

        1. Are you a doctor? Why would you be giving her any opioids if you weren’t a doctor or drug dealer? And you have the balls to judge her?
          It’s people like you that have legit pain management patients jumping through hoops just to keep their medication.

    2. Stephanie I was on subutex when I was pregnant too and if your having a problem with bad headaches it could be due to the subutex. What I learned is methadone is widely more studied in pregnancy.Its up to you and what ever you decide should be thoroughly thought out not only for you but for the baby too. But methadone is a lot harder to come off of. I’m still going down on my dose for four months now and I’m not even half way but I’m doing it very gradual. Again it’s up to you and what’s best for the baby. Subutex doesn’t have the naloxone in it like suboxone does, but the naloxone isn’t absorbed. To be honest normally your only prescribed Subutex or suboxone if you have an opiate abuse history otherwise they would give you bubucal or the butans. So not saying that is the case but if it is for your sake don’t take the oxy it could send you back into active addiction and that definitely isn’t safe for the baby. So think about it and talk to your doctor. I know I’m not one So I’m just saying something you can bring up to talk to your doctor about. Hope that helps and congrats on your upcoming little one. They really are a joy in life. And I left my email if you want to talk more about it.

    3. Stephanie……PLEASE….READ THIS…..There will ALWAYS be judgementalpeople..They’re so sanctimonious that their verbiage ends up CAUSING fetal (in this case) harm!!! WHAT YOU DON’T KNOW ABOUT YOUR PRENATAL….CARE…U ASK!!!! DON’T LET ANYONE MAKE U FEEL STUPID FOR ASKING QUESTIONS TOTALLY GEARED TO “HARM REDUCTION!”
      Blessings to you and your baby.❤

    4. If I where you I would really try massage, stretches, or heat and ice to try to protect the baby from as much chemicals as you can. I had sinus issues and headaches with both my pregnancies and the massages and stretches worked for me. Now not being pregnant I use ice a lot and that helps me to this day.
      I hope this helps, oh and it may sound dumb but my cousin told me meditation too.

      Good Luck,
      Ruth

  84. I was started taking oxycisone for severe headaches and my chronic back and neck pain again when I became pregnant. I didn’t have a current prescription because of no insurance and no pain management doctor so I was using old scripts I had from previous er visits and old pain management doctora or from family. The ob sent me to neurology who sent me to pain management who wouldn’t treat me because of the pregnancy. My ob then sent me to a clinic to get on subutex to hopefully help with some of the pain but also so I wouldn’t withdrawal and harm the baby. My headaches had started to lessen and so did my back pain, or so I thought, now wondering if the pain meds helped more than I thought, because since taking the subutex I have a constant headache to goes up and down during the day, at the worst I can’t move and I get nauseous or throw up from the headaches and my back pain has gotten a lot worse as well. The clinic recommends that I go back to my on and demand to be treated with pain medication but I don’t think I’ll have any luck because of all the “pushing around” to different docs that happened before I went to the clinic. If I had ins and had been in pain management prior to becoming pregnant this wouldn’t be an issue, they would continue to manage my pain. I had headaches with my fittest pregnancy and was on pain medication thru my second trimester and then weened off when my headaches lessened towards end off pregnancy before the delivery and I’ve informed my current ob of this and told them is like to do this again but again they told me to go to the clinic for the subutex. Not sure if you have any advise on what I could rake safely that would help or what I should do in this situation, but was reading all the questions and figured it couldn’t hurt to try for some advise. Any advise if possible is greatly appreciated. I feel like everyone is just pushing me off to another doctor, and while they don’t want me to go thru withdrawal and risk hurting my baby, they also aren’t willing to help me in any way.

    Please don’t judge, I used pain medication with my first pregnancy for the first and most of second trimester and my son is 12 and doing great and I was off them before he was born. Living with chronic pain and then finding out your pregnant on top of that is stressful enough and I’m just trying to do the rift thing for baby AND me, unhealthy unhappy mommy can harm the baby as well. All my checkups and anatomy scans are perfect and nothing is wrong with the current pregnancy.

    1. I meant to change this post and jyst ask if I could take an oxycodone here and there while on the subutex. I need to stay on the subutex to avoid withdrawal symptoms from being on the pain meds because the doctors will not prescribe them for my headaches or back problems because of the pregnancy. I can’t take Tylenol, it doesn’t agree with my system and cant take ibuprofen because of the pregnancy. I don’t want to take the pain meds all the time, but just for when the headaches turn into migraines and I cant function or eat. I know while on the subutex they won’t be as strong but if they help even a lil bit, I’ll take it. I jyst want to make sure it won’t send me into precipitated withdrawal like I heard it does with the suboxone.

    2. I meant to change this post and just ask about taking an oxycodone here and there while on subutex. I know it won’t help as much as it normally should but if it helps relieve even a lil bit of my migraines then ill take it. I just want to make sure I won’t go into precipitated withdrawal like I heard happens with the suboxone.

      1. Ask ur Dr for imitrex for headaches it worked for me and lasts for quite awhile. No addiction to worry about either.

      2. I got headaches while I was on Suboxone and every time Excedrin Migraine took them away like nothing. And that was only half a pill. I suggest that first. Good luck!

      3. I posted something about this already, but one other thing that causes headaches on this medicine is being on too high a dose. Just something to think about.

    3. I understand completely! When you’re in pain, you have thoughts go through your head that normally wouldn’t be there! You just want to be out of pain!!! However, Subutex gives you headaches, and these headaches are not your average run of the mill headache! It is listed as one of the many side effects. No narcotic pain med will work while you’re taking Sub. Ibuprofen worked WONDERS for these headaches!! I took 3 ibuprofen with 1 Tylenol. Ask your OB if there is an alternative that will be safe. Unfortunately I think a low dose narcotic pain med would be safer as a one time use, but what happens tomorrow when the headaches return, ya know? It’s one of the MANY sacrifices we mothers make to have our children happy and healthy!! I took Subutex for years after opioid abuse, and have since successfully come off Subutex. I no longer crave opioids, and have managed, in my opinion, a successful recovery with Subutex and mental health therapy. Feel free to ask me anything! I’ll be open and honest with my experience. Good luck to you!!!

    4. PSA (Public Service Announcement) AKA NOT A JUDGEMENT TO STEPHANIE

      But anyone with a live fetus living inside of them (meaning ANY and ALL pregnant women) who imbibes or ingests ANYTHING besides food, vitamins, and the necessary medicines, tonics, or elements needed to grow, nurture, and protect that innocent, defenseless life IS in need of a reality check

      If you take anything besides (god forbid) an antibiotic in case of some kind of infection or illness while you have a baby living in your womb, you are INTENTIONALLY hurting the baby and you should be stopped if you do not stop yourself.

      If this is leaning towards a “handmaiden” (aka feminist nonsense) rebuke, I couldn’t care less….the “feminists” of this era are more concerned with silly self expressionism rather than their natural role given by nature which is to be the giver and preserver of sacred and fragile life.

      So sorry to Stephanie or anyone else who doesnt want to hear the truth while scavenging for a cheap high – you should be protecting and nurturing that womb. It is your sacred duty, whether you like it or not, as I suggest you think of asking the baby in 15 years what he/she would have done in your position, and maybe the answer of what you should be doing will be obvious

      PS We ALL have terrible pain here, which is why we are all here. But we also all know, pain has an addictive quality of its own. I can skip a day or two of my pain meds, and I can handle it with a lot of struggle. Life is struggle. While pregnant, a fetus doesnt need to fight off a toxin like Buprenorphine-it needs all the life, nutrients, energy, and faculties to enter this world at its most optimal level

      ANYONE, especially, any MOTHER, who thinks you can do no harm to the fetus while still “doing you” (tisk tisk), getting high, or whatever, you are wrong, and you are literally, abusing your baby while its in your own body….if that’s the type of mother you are going to be, maybe think of adoption since your drug and getting high is more important to you than keeping such a precious little gift of a human baby alive and safe

      END PSA——-

  85. Dr. Fudin,
    Thank you for this article. I have been on Hydrocodone for about 3 years. Prior to that, I was on Tramadol, which was completely worthless. I started on Hydrocodone at 2.5/325 and developed a tolerance, so my doctor gradually raised my dosage. I’ve been on 10/325 for a year now and it isn’t helping nearly as much, so my doctor put me on Belbuca 150mcg. I have researched and researched, but I can’t find the answer to my main question: If I stop all Hydrocodone, will my tolerance decrease? Is there any way to lose my tolerance for opioids while still managing my pain? Thank you for your help!

    1. Russel,

      Yes – your tolerance will decrease over time with less exposure to opioids. That is why there is such a high prevalence of opioid overdose deaths among people recently released from jail. Many times they go right back to the dose they used prior to serving jail time, they not longer have the same tolerance, and the result is death.

      1. I am impressed with your credentials and have a question. I am an RN who has had two spinal fusions from L4 through S1. I have progressive spinal stenosis at L 3-L4( severe) and L2-L3 moderate. I have asked to switch from Nucynta 50 mg Q8h to something I could try to wean myself off of if possible prior to another surgery. The reason for this is lack of pain control after surgery. Do I just switched to the Belabuca 300mcg Q12h. Will this be a dramatic drop in covering my pain? Thank you

        1. Karen; Belbuca May work better or worse especially at the doses You acknowledged. For the record, it is rare to have withdrawal symptoms from discontinuing Nucynta and if there is withdrawal it’s minor.

          1. Hello Dr. Fudin,
            I was taking what I thought was oxycodone but turned out to include both heroin and fentanyl…they were taken while I was living in another country. During the past year I managed to get help and get on Suboxone. Similar to Karen’s situation, I had an accident back in February that resulted in broken bones, most importantly a compression fracture of my L4 vértebra requiring surgery. So, I weened myself off Suboxone so that I would have pain management available to me after the surgery. I’ve had the surgery and it was successful and I was given a prescription for the 10mg Percocet. But my tolerance is so high that i have to take quite a few to get relief. I am at a point now where I want to stop taking this prescription. I’ve only been taking the Percocet for a little less than 3 weeks but I can tell when I wake up in the morning that I am having withdrawal symptoms. I know I should wait until I am in full withdrawal before taking Suboxone. I also have a few transdermal 10mg Buprenorphine Patches. Would you recommend I go back on the 8mg sublingual strips I was taking before my surgery to help with withdrawal symptoms or would you recommend I use the 10mg transdermal patch? I don’t need the Naloxone portion because I don’t have cravings, just the other symptoms. I don’t have health insurance at the moment as well which is why I haven’t been able to talk to my doctor. I just want to make the switch from Percocet to Buprenorphine as soon as possible so I can lesson the withdrawal effect and then ween off of the Buprenorphine just as I did prior to surgery. Any advice or recommendations are very much appreciated. Thanks, Ed

          2. I was prescribed 12 20mg oxycodone after my surgery then 6 15mg for pain management until I lost my insurance I just got it back went to pain management and they gave me 75mcg belbuca it does absolutely nothing for pain how do I tell my dr without him thinking I’m pill seeking the only time I had a decent quality of life was when I was on the 6 15mg codones but he told me to take what he gave me or find a new dr heroin and greedy drs have made it impossible for actual chronic pain patients to get help I’m at my end and to the point of just buying them off the street because this is ridiculous

        2. Kareb Tabb, I am also an RN with a fusion from C4-C7. I had no problem weaning off Nucynta. I did not stop it ovenight, but did taper over the course of a few days, and the only side effect I had was some irritbility and GI upset. Nothing like weaning off any other Narcotics I’ve had over the years since my three-level fusion. I started Belbuca not quite a month ago, and tend to underdose my self, because I am not in pain and forget to take it! That’s a first in 5 years!! So, clearly, pain relief is vastly improved, compared to Nucynta, The side effects, for me, are a little worse, still, with increased “dopiness” and a little diziness and I don’t get that lift or “sense of “wellbeing” – not really euphoria – that I did get with Nucynta. I sense that the side effects will continue to dimnish over time – they already are. I do miss that over-all “relief” that I felt on Nucynta, but I clearly have better pain control, and I am never tempted to reach for anything to bump-up pain relief, but rather maybe a half-cup of coffee or a couple of sips of Red Bull to get me through a morning or afternoon of fatigue or “blahs”. I much prefer the latter – it feels so good to feel more in control of my pain, now, rather than a slave to my pain’s intensity! Stick with the Belbuca…even if it seems overwhelming in the beginning…it doesn’t act like Nucynta – and that could turn out to be a very good thing for you if you give it a chance!

          Good Luck – I imaigine you will have the same sort of experience that I did! .If not, don’t forget that you still have options…you still are the boss of your pain!

      2. Hi Doctor,
        I have ddd and spine pressing on the sciatic nerve. Specialist says he may not be able to offer a surgical solution although I have one more mri to go to before he decides. Anyway I’ve shunned pain meds as I don’t want to be reliant on opiates and I wanted an operation and hoped to be back to myself. But the pain has gotten so bad over the last year especially, I can’t walk more than 10 yards then this searing, excruciating pain sets in all the way from my big toe to my lower spine. Sometimes I skip meals because the pain is too excruciating to potter about. I spoke to my doctor and he said we’d try codeine and paracetamol first (I know it won’t work as I’ve had it before) with a view to going on Butrans when it doesn’t. I’m asking this next question here because I feel like an addict asking my doc. Question is if I go on the butrans and still get breakthrough pain … is there anything they can give me on top ? or is the patch my lot ? would I then have to try another opiate if the patch doesn’t control my pain ? I don’t like asking my doc these questions because there are a lot of sneaky addicts where I live and the docs ARE suspicious … and I feel like an addict asking … like I’m only asking to get as much opiate as possible … which I’m not.

        1. Andy,

          You will get some benefit from an opioid such as codeine (or another) while you are on Butrans and also could benefit from an anti-inflammatory if there are no medical contraindications. If Butrans transdermal doesn’t work, another option is Belbuca which comes in higher doses compared to Butrans and is more readily absorbed.

  86. Hello Buprenorphine Experts!

    I am currently on 32 mg/day of sublingual buprenorphine (generic Subutex). I have noticed a significant improvement in every area of my life, except for some minor hair loss, which is admittedly frightening. However, I am trying to find out if I can switch to the Butrans patch so that I won’t have three periods throughout the day where I can’t (or weirdly) talk while waiting for the medication to dissolve under my tongue for 25 minutes. Is the 20 mcg/hr 7-day patch equivalent to 32 mg/day of sublingual buprenorphine? If someone can answer this question, I would be TREMENDOUSLY grateful, as having to take this mediation two-three times while working is really creating a situation where I feel like I have to hide for 25 minutes or focus on paperwork only, and avoid the phones/co-workers, which negatively impacts my ability to generate income and improvements for my firm. THANK YOU SO MUCH IN ADVANCE. Sincerely, Travis K.

    1. Travis,

      There are no studies that directly compare the equivalence of these two drugs, but mathematically and based on percent absorption, the highest dose of Butrans if far less that what you’re receiving. The dose of buprenorphine needed to treat pain are significantly lower than doses needed to treat opioid use disorder, so, Butrans Transdermal 20 may work just fine. You should discuss this with your doctor.

  87. My doctor prescribed 1 to 1 1/2, 300mcg Belbuca patch, Twice daily. Package says not to take off broken or cut. I’m very hesitant to break in half and take. Please advise. Thanks!

    1. You should discuss this with your doctor. They are not intended to be cut and it will affect absorption. There are other options to get to that dose without cutting the films.

  88. Please someone help me!! I dont take suboxen or subtex.. I am being drug screened twice a week and am testing positive (urine)for buprnorphine. Now either one of my prescriptions is causing this or having sex with my partner who does take suboxen. Question is how do i prove that im not taking it??

    1. They say it’s highly unlikely, but I can safely promise that my wife got seriously dope-sick (I’m a pain patient, not using it for addiction) three times; twice when she kissed me right after a dose and once when she drank from a soda can that I had just spat my spent medicine into. I could not have felt any worse for that last one, still makes me feel guilty as hell when I think about it. I called and told my doc and the clinic argued that it wasn’t possible in such a short period of time, but she’s ope naive and would readily testify to that horrible, 3-day experience. She three up for 72 hours straight and had to miss work, and she’s experienced just enough to identify that unmistakable misery (hell, we were both in college once, so don’t judge) so I am certain that you’re right, and definitely right to worry in the future. Great topic, thanks for your post!

  89. I was previously on 5mg Opana Ir (5mg 3xday). When Endo pulled that, I was switched to 300mcg Belbuca. This seems to work well for me with almost no side effects. For breakthrough pain, I have Norco 10-325mg as needed. I have 2 questions. 1)Is my dose now the equivalent or more than my Opana dose? 2) Is Norco effective with Belbuca at this dose?

    1. Heather, There really isn’t an equivalent of Opana to Belbuca because Opana is a full opioid agonist at the mu receptor and Belbuca is a partial agonist at mu and full antagonist at kappa receptors. It is far more complicated than that, but Belbuca could offer the same benefit a these doses. The dose of Belbuca is low enough that some of the unoccupied receptors can combine with Opana for some benefit. As the dose of Belbuca increases, there will be less benefit to Opana or any other full agonist.

      1. Sorry but this is not a reply to your comment it’s just the only way I saw to leave a comment. I have been on 12 mg of Subutex for about 2 years now and was just prescribed Oxycodone 10mg for an injury I suffered at work. Is there any sense in taking the oxycodone? Would I gain any relief from it? Or do I run the risk of being thrown into withdrawals?

        1. Linda,
          You can Google any tablet you question. Simply type in the imprint that appears on one or both sides accordingly.

  90. Dear Pain Dr.

    I have been on hydrocodone and oxycodone, intermittently, for several years. I started on 5mg Vicodin, then upwards to 7.5 and 10……then after an even worse accident than before, I was put on oxycodone 5,7.5,and 10 as well. (I’m a victim of violence as well as having nerve disease and physical damage from accidents).

    I am now on 450mcg of Belbuca, twice daily. It was working very well. However, now its less effective. From reading the posts here, I was led to beleive 450 should still be working. After 9 months, do I need an upward titration/increased dose? (600mcg?)

    Thanks

    1. I just saw a new report compiled by Sanjay Gupta where Buprenorphine PET scans showed neural misfiring and just simply a dulling of cognition it seems (prefrontal cortex), and opiate use long term apparently makes that worse.

      Additionally, CBD and THC can provide adequate relief, without any bit of a trace of harm, dependence, or addiction. Most of all, perhaps was the point that the marijuana actually helps heal the body, in that inflamation and increased immune strength help.

      I checked further: There is an endogenous cannabinoid system inthe body that has been discovered to have a DIRECT correlation on the immune system. It seems to me, in my lay understanding, that this actually is a secondary immune system that can be activated with marijuana.

      Lastly, its anticarcinogenic for the entire system, but more importantly the brain….

      Ive noticed degeneration in my cogition, memory, and other things so I think in light of all this, and that Medical marijuana exists in over half the country, I’m willing to try.

      What is your response to.this dr?
      I’d love to have my brain repaired while being as pain free as possible. I’m on such a low does of belbuca i think it’ll be easy to do.

      Thanks

  91. I’ve been on
    butrans patch 5mcg for about three years for chronic neck pain. I want to stop taking it. Can you suggest any advice to handle the withdrawals? I’ve tried before and at about the 2 day mark my legs became so restless at night that i could not sleep and even started to affect me during the day. Is there anything i can take to help with the withdrawals? And how long do the symptoms of withdrawal last?

      1. Hi. Dr I’m in a lot of pain my dr percribed me 300 mcg of belbuica how dose this compare to fentayal in mcg cause I was previcly on 50 mcg of fentayal and Norco 10/325 I’m nervice cause they tried me on butran 20 mcg already and they didn’t help at all and even with insurance these medications are extremely expensive I no these new laws are a little to late and are un American they are going after the pharmaceutical company drs if they was going do this they should have done this 20 years ago not wait till the streets are flooded with fentayal laced heron is this belbuca even equivalent to even the norco 10 cause the butrans I was on didn’t touch the pain

  92. Want to pose a question i am finding very difficult to get an answer for.

    Im on subutex 10mg daily sublingual but i have been on this many years and it does nothing at all for peripheral neuropathy in hands and feet or for tendonosis in shoulders. My pain clinic doctor has recommended i try tapentadol slow release in a low dose. I am almost certain the subutex will block the tapentadol’s action altogether. Ive heard tramadol doesnt get blocked by subutex but in theory perhaps but in practice Im not so sure. I once had a dental absess and i tried a very very silly high dose of 50mg tramadol. Was lucky not to get seratonin syndrome it was so many but got zero relief and didnt feel a thing.
    Perhaps it was just so weak compared to the subutex. Any help would be greatly appreciated.

    1. Sebutex will block the VERY weak opioid activity of tramadol, but it will not block the NE and serotonin reuptake, the latter (NE) of which is important for neuropathic pain. Essentially it would be similar in pharmacology to taking venlafaxine or duloxetine but with more constipation. Tapentadol opioid activity will be blocked as well, but that also blocks reuptake of NE, which will not be blocked and which is good for neuropathic pain.

  93. I just started Belbuca about a month ago at a 450 mcg Q12 hour dose after years of being on different opioids. It has done a great deal to manage my pain and has been better than I expected. The problem is that since I started this medication, I have a lot of extra energy, headaches, and feel somewhat jittery. I’ve just read that this might indicate a rare but severe adverse reaction. In addition to chronic pain. I have been depressed for several years and honestly this is the best I’ve felt. I have a few questions if I may…Is this a severe, dangerous reaction? How many hours after you take your dose, does the medication peak?

    1. Mike,

      Being “jittery” is generally not a reaction from buprenorphine unless a person is on a full agonist opioid such as morphine, oxycodone, or hydrocodone, in which case it would cause the jitters from withdrawal. The peak is within the first three hours. If you’re having headaches or jitteriness, you should seek an evaluation from your medical doctor.

        1. There is no exact equivalent of one to the other and they have not been studied to make that comparison. Belbuca and Butrans are manufactured for the purpose of treating pain, and the doses are very different for that which is required for opioid use disorder. If your doctor is treating you for pain, not an opioid use disorder, the doses available for Belbuca or Butrans should be fine and minimize side effects.

    2. you are feeling the “high” from the medication. this usually goes away pretty quickly as you get used to the medication and you opiod receptors get absorbed with the medication. the half life is a lot longer than 12 hrs taking the next dose at 12 hrs while you still have medication in your system.

      this was posted in april so you should be feeling normal by now.

      good luck with the depression, in rare cases opiods are used for depression in very small amounts. too much has the opposite effect

  94. I am trying to grasp the information I just read through. I feel like I’m on overload and want to be certain I am grasping these posts. After reading all this I believe that this is saying with physician treatment it’s possible to stop long term Fentanyl dosing replacing it with appropriate levels of suboxone to achieve pain relief. This is safe to do without first weaning the Fentanyl. right? Also, it is possible that the patient would not suffer withdrawal nor have issues of pain management dependency and if the pain is controlled well with the suboxone it also may be a way to wean Suboxone until either a maintenance dose is found or pain medication is not needed. I just wanted to be certain I understood this because if that is true I will be printing this and heading to my doctor to talk. Thank you for all your information it offered a ray of hope to not have this difficulty.

  95. The textbook chapter on perioperative management linked above is a drafted version. Has the final version been published or is it available electronically?

      1. I, myself refuse to take any Anti-Depressants.
        If my mom who’s now deceased and NOT from opioids. Btw. But prior, if she forgot to pick up a refill when she ran out of her antidepressant for a couple days. She was a serious wreck. I’m talking a mental mess, so I had to rush out to get that med asap to get her back to normal. I can’t imagine trying to get off any of these antidepressants. Its just as bad if not worse than pain meds. There’s loads of reports and conversations online of people who are trying to get off these particular drugs when they were used for off label, of course other than clinical depression. Seems Drs give antidepressants out like candies for nearly anything and everything nowadays and I’ll bet most people have no idea how dependent they’re going to end on them.
        On another topic, It’s really scary where pain management is headed these days with so many patients being forced onto Buprenorphine if they’re needing constant pain relief.
        A whole lot of have been replaced on this to because of a chance euphoria could cause addiction. We all know that the percentage of true pain patients ever feel that or become addicted.
        But besides that;..
        We know that all drugs come with plenty of sides effects that can harm people far worse than just the plain old opiate medication and not to forget about NSAIDS.
        Why is it that Buprenorphine, “one drug” for all patients who need higher doses is now the best alternative for every person with chronic pain requiring round the clock pain relief? Sure seems this way. I hear from many who are still in agony.

        If this it and bupe is the only one, then Why were there so many other different kinds of opioid pain medications developed in the first place if one drug is supposed to work for everyone? We’ve all heard from pain patients who had to try several different opiates before they found what worked for them?
        I’ve heard from patients that nearly all pain Specialist are pushing this Belbuca. If it doesn’t work for you, your screwed, too bad if 90 mgs isn’t effective for you.
        Besides that, those Patients have into withdrawal before beginning Buprenorphine.
        This is Torture treatment. Double Jeopardy to Legitimate pain patients.
        In case folks didn’t know, America is headed to zero pain management unless 90 mgs or bupe works for you. Only the dying or those headed that way get proper pain relief. Pallative care seems to mean nothing either.
        Our Drs are getting out of PM in a hurry . Unless they’re doing Injections, procedures, low dose meds or Bupe. Patients are stressed out and doctors are scared to death to treat pain. The DEA in FL is visiting Double Certified Pain Management Drs now. As of July 1 2018.

        Ugh.. benzodiazipines another subject for a different time.

  96. Hello!! Are there any other sites on my body that I can apply the Butrans patch to? I have “benign keratoses” in many of the sites that the manufacturer recommends, which make the itching problem with the adhesive much worse–to intolerable. I’d greatly appreciate any help because I have severe chronic pain in 3 areas of my body is I don’t like adding itching to the list of discomfort!! Thank You for your help and very informative web site. Martha S.

    1. Martha, This type of reaction can affect absorption. I’d speak to your doctor about two options; 1. Use triamcinolone topical aerosol spray prior to placing the patch (requires and RX), or 2. Discontinue Butrans and try Belbuca which is administered inside your mouth on your cheek. If insurance doesn’t cover Belbuca in favor of Butrans, this is a very reasonable appeal that will likely get approved.

  97. My wife’s insurance said they cannot do butrans but only belbuca. She been on butrans 10mcg and doctor had now changed her to belbuca 75mcg every 12 hours. Just got a message from drs office saying they did the change. Going to call them on transition and anything we should know.

    So is belbuca better than butrans? Will there be any withdrawal symptoms with transition? On dosage is 10 and 75 on same level. Thanks doc.

      1. Bupe is crap. Worthless as a pain medication. RB admitted it is not pain medication. Anyone with true pain used as a Guinea Pig can confirm this…

        1. You are 100% ABSOLUTELY CORRECT! After being on Suboxone for almost 4 years, my opiate tolerance has SKY ROCKETED! Now, I’d have a better chance pulling all my teeth out with a pair of pliers before I will get approved for a life insurance policy. People, please know ALL THE RISKS before being prescribed Bupe. This whole insurance and pharmaceutical industry is a joke!

  98. My daughter (Age 21) has been on Butrans 20 for since 2013. It has been the best pain management we have found. However she has allodynia, adhesive reactions and sweating related to the disorder, so the delivery system via patch is not ideal. So dr. prescribed Belbuca. However, insurance keeps denying this, saying we need to try other therapies first. This makes NO sense to me because we are switching from buprenorphine to buprenorphine. How do fight this? She CANNOT tolerate screwing with her meds again!
    Would appreciate ANY help you can provide

    1. Based on what’s going on these days, I would have an attorney draft a document up to sue them. I would site the opioid epidemic and how RN outing more addicting drugs because of cost alone would result in harm. Not sure if this will work but it will sure make them look closer.

      1. This is the exact approach I took. I went through 3 rounds of appeal to no avail. The insurance companies simply do not care. I pay 100% myself. The insurance companies have pain patients over a barrel. The traditional opiates are dirt cheap and they don’t pay a dime if they deny coverage for better meds. It’s abhorrent to pay for a product who dictates your use of that product. Praying new admin. brings back major med plans so I can simply drop generic coverage. Health ins is a giant waste for basic needs. CEOs continue to be enriched with 7 figure salaries, while consumers fight for coverage of life saving meds. There’s a special place you know where, for suits in ins companies. When profit is tied to healthcare the outcome will usually not favor the patient. I’m against universal healthcare, but I do believe profit should be capped to stop what’s happening now. How much money do millionaires need? Sorry, I digress.

        Best of luck. I got nowhere with BCBS!

    2. I had a siimilar issue. Ive been on opiates almost 10 years, and for some very strange reason, belbuca (which costs less than Butrans and some other meds I’ve been prescribed) has been met with the most opposition in fulfillment….which i really think is odd because it is the single most effective, safest, and efficient opiate I’ve been on. Ive been on all of them except the super duper heavy ones that only cancer patients or repeated surgery patients are on..

      Also, I have hyperhidrosis, so when Butrans kept falling off, I had almost more difficulty from going into withdrawals every 3 days than having no pain meds and being generally miserable. In other words, I kept having anxiety attacks and the withdrawals because my patch would fall off by the time the peak plasma levels would start to kick in…. at one point, I was ripping off and reapplying a patch every other day with tegaderm, which costs $25+ a week on top of all other costs…..

      Point being, only after 3 appeals and a month of waiting, I finally was able to show between my multiple diagnoses, my years of opiate use, and the medication problems i was having, especially as per my specific medical ailments, i finally was approved

      But it was long, hard, and i was doubtful. I was worried that after finding the single most effective drug for pain (Buprenorphine) I’d be denied but luckily there are indeed multiple formulations ….

      It’s a truly amazing med, and I wish ALL opiate patients (especially on OC) would switch to belbuca only for the fact that I personally see it kills chronic pain {not acute for some reason] as well as fast acting pain killers.

      That actually bring a question to mind Dr. Jeff:

      why are the bupeprenorphine PO/oral pill forms such a high dose in comparison with a patch or film used for pain *

      thanks doc

      *(in other words, is there a psycho active effect or elements at the milligram level used for addiction… I’m curious why the addict needs exponentially more than the chronic pain sufferer, like an addict may receive 2-8mg in a single dose but a chronic pain sufferer gets less than a milligram for the whole day? Seems like it would be the other way around but I’m not a doctor so I thought to ask )

    3. I have been taking Belbuca for just under two years. I had been prescribed Percocet for a ruptured disc and had trouble stopping. I was clean for over 17 years. My max dosage was 450 mcg 2X daily. I had weaned to 112 mcg 1X daily. Now I am on 75mcg 1X daily. My question is do I continue to wean? At what point do I stop?

  99. Hi I have just been switched from 8mg suboxone twice daily for chronic pain to belbuca 300 mcg twice daily. My pain is not controlled at all by the belbuca. My Dr said the belbuca 300 mcg is equal to the suboxone 8 mg per morphine equivalent. This doesn’t seem possible especially since my pain is so bad after the switch. Is this information correct? I actually asked to be swapped due to the stigma related to suboxone. Many health care providers are very judgemental when they learned I was on suboxone. Im a post cancer and chemo patient with many other health problems. Can you please help me understand? Thank you

  100. I was taking suboxone 8mg for 2 and half years. Got pretty good pain relief from it but also got energy. Not euphoria, but energy. I’ve always understood its not a tool for getting high, nor do I want to get high off of buprenorphine. I just recently switched to belbucca 900 mg. The pain relief seems to be working very well. But it does not seem to produce the energy suboxone did. Why is this?

      1. Sorry I don’t follow

        I am now on 450mcg and it seems to be my maintenance, I doubt I’ll need an increase anytime soon due to the antagonist properties, correct?

        in other words , once you get the right dosage you don’t need to increase it?

        1. Belbuca has fewer peaks and troughs compared to Suboxone. Because buorenorphine is a partial agonist / antagonist opioid, you will not have the same dopamine influx to the brain which is otherwise partly responsible for tolerance and increased doses. So you are correct; once you’re stable, you should be fine.

          1. Thanks doctor

            If I may, how is it that Belbuca * BA is over 100%?

            it seems like according to the clinical study trials, proper application produced a BA of 130(?)% in one setting at least

            And also, is that what makes it so expensive?

            The ROA is so much better and safer, there is no potential for abuse (at mcg doses), and obviously the formulation is proprietary BUT the main ingredient (buprenorphine) is markedly less …

            Meaning sublingual and tablets of 2-8mg [please correct me if I’m wrong] contain significantly much more of the drug , so why is the buccal form with less drug cost more??

            And finally, you mentioned dopamine; is the pro-drug the reason that belbuca is so costly, as the metabolites seem to contribute quite a bit to the analgesia

            At what point is dopamine secreted , as in …I’m trying to understand why the same drug is used by addict therapy and pain management , but they are indeed very different at the end of the day

            (PS Do people who take 2mg-8mg ,pill or sublingual, experience 12hr analgesia ?

            *(which is the same buprenorphine used for sublingual or tablets; however the dosages and ROA are what differ)

      2. Hi you seem to be knowledgeable and have a question why would my dr give me 150mg of belbuca along with my normal norco for my severe back pain? Thank you

        1. Cindi, This is a very good question. At moderate to high doses of buprenorphine, hydrocodone will not combine with opiate receptors and therefore will not be effective. A Belbuca dose of 150mcg twice daily is relatively low. At that dose, there will be some unoccupied opiate receptors to which the hydrocodone can combine and provide pain relief for breakthough pain episodes. You should discuss dosage plans moving forward with the precribing clinician.

    1. Because you have a paradoxical effect of higher energy under the influence of opiates and considering how potent buprenorphine is, the decreased amount of opiate in your bloodstream has resulted in feelings of lack of motivation and energy. I would bet that oxycodone while great for pain and an extreme depressant in opioid naive patients, would give you the energy to do the work of 20 men. I would recommend taking a serious look at the lkelihood your life lives and dies with opiates. I wish you the best

      1. Wow that sounds meaner than I meant it. Science will catch up to meet the needs of patients like you without the terrible consequences that opiates can have, good luck brother

      2. Matt; I am not taking issue with what you’ve just said, b/c I don’t understand what you’re saying.
        “I would bet that oxycodone while great for pain and an extreme depressant in opioid naive patients, would give you the energy to do the work of 20 men. I would recommend taking a serious look at the lkelihood your life lives and dies with opiates. I wish you the best”. Are you talking about addiction or dependence issues here?
        I’m on Fentanyl patches for severe Fibromyalgia pain (which is possibly secondary to a benign hemorrhagic macro-adenoma in my brain). I’m dependent on the pain management to manage my pain but am not addicted to it. When I’m not in pain I completely forget about being due to replace my patch, & there have been several times when I didn’t realize that I had forgotten to change my patch until the following day when it wears off & the pain creeps back into my life. Addicts don’t forget to take their medication, so is that what you mean by the likelihood that someone’s life lives and dies with opiates?

    2. It seemed as if I have had more energy with the suboxone as well but no euphoric feelings. It seems to help my chronic fatigue from my Lyme Disease but it is only temporary and now I’m not looking forward to switching back to oxycodone for my ruptured/degenerative discs & stenosis. The biggest issue for me is that now I can’t take my xanax for my ptsd/panic/anxiety attacks while on the suboxone. Its like a catch 22 because I am having more panic attacks after reading about the dangers of suboxone but it helps with my pain, fatigue and concentration. Guess I just have to choose the lesser of the evils. Thanks for sharing this post though because it confirmed that the way I am feeling(overly efficient w/o being over-talkative/euphoric?) is from the suboxone and probably from the pain relief it has given me. This gives me something to think on and discuss with my doc on my next Pain Management appointment.

  101. Great articles and discussions

    To be as succinct as possible: I had nerve/CNS damage from child abuse (including mercury poisoning [12x]that required 2 chelation courses of metoxol; amputation and re attachment of 3 fingers ) and spinal stenosis: C5/6 And L3 herniation, lumbar radiculopathy;) and scoliosis,straightening of neck, neck arthritis , and PLMD.

    I was on Vicodin for 3 years, oxycodone for 1 (oxy formulation is so addictive I was on OxyContin for 1 month and went right back to IR); but then had to go back down to norco voluntarily. This with Lyrica 300 BID.

    Eventually Vicodin stopped working at the levels I set as self-imposed ceiling (10mg barely did anything and I wasn’t going to feel any more withdrawals)

    so besides my Dr. being jailed for robbing Feds of $58 million through his pill mill , I went to a new guy who was recommended and I just had my first baby so I NEED to cover back pain

    Told him Lyrica is life saver for neuropathy but the spinal damage needs an opiate. He started butrans which was great but I have hyperhidrosis so after day 4 I stared withdrawals . BUTRANS DOES NOT WORK IF YOU SWEAT.

    Moved to belbuca and at 300mcg, I’m starting to feel close to finally living almost pain free. I’m going to see him next week to up to 450mcg and that should do it

    I highly recommend it, as buprenorphine is the BEST opiate I’ve used for chronic long term pain management. Belbuca seems to be the most intelligent pharm to date because of the BA, ROA, and application are all around the best.

    Only 2 issues:
    1. The film doesn’t always stick properly, and or the film is cut or damaged in production so sometimes you get a dud
    2. Acute/breakthrough pain requires Oxycodone , which I don’t get

    Two questions:
    1.)according to lab results, you should feel FULL analgesia 2.5 hours after the initial application ? Is that accurate ? When does initial analgesia theoretically start though?

    And when is the buprenorphine film fully applied/introduced to the cheek? I know it says 30 minutes but that’s for good measure, it’s really how long for 75% to work ? Because with my Lyrica my dry cotton mouth needs water every 10 minutes …so I need to know when I can sip water after..

    Thanks

  102. I’ll just give the facts of my personal medical history.
    *I’ve had 2 spinal fusion surgeries, 1st surgery L1-L3-10yrs ago, 2nd surgery 4months ago, a redo on L1-L3 and added L4&L5. I also have drop foot and neuropathy due to nerve damage.
    *Ive been on fentanyl starting at 50mcg I am now at 150mcg every 48hrs in the beginning I was using 20mgs of Percocet for break through pain, since my most recent surgery the Percocet was changed to 20mg of oxycodone…
    * Here is my question??
    2 days ago I went to my P.M. Dr. unfortunately my normal Dr. was on vacation for 3wks for I saw another Dr. in the practise.
    I told him I was so tired of taking all these meds so he changed my meds and being naive I agreed. The Dr. I have seen for a year and a half said I should wait to do a med change that my fentanyl dose is really high (she wanted me to drop over the course of a year from 150mcgs to 50mcg before we tried anything new and she was refering to buprenorophine). She believes I am still post surgery and I should give myself more healing time. I have no life at this point because the pain is honorific however: I can at least sit now pain free which is something i could not do pre-surgery.
    The substitute Dr. that I saw told me to take my fentanyle patch off and replace it with the Butran patch and changed my oxycodone to 30mg instead if 20mg for break through pain.
    I did my research and I know all about buprenorophine. I understand that suboxone has naloxone in it which makes it slightly different but buprenorophine is buprenorophine. Suboxone and the butran patch are opioid partial agonist and I also understand that if buprenorophine isnt started the right way it can put a person into percipitated withdrawls and this is my biggest fear.
    Do I have to be in moderate withdrawls before I apply the butran patch? I realize Drs. do prescribe break through meds along with the butran patch but i believe a person has to already have the buprenorophine in their system if its the other way around I believe percipitated withdrawls can occure and those scare me to death. Over the last 24hrs I’ve reached out to my Drs. Office 4 times and no one has returned my call. I’m so tired of being in pain and I’m just as tired of being on pain meds that do not seem to give me much relief. I am willing to try anything different but I do not want to apply a patch thst could make me very ill. Please help asap Im lying here in pain trying to decide what to do or not to do. Should i apply the buprenorophine patch or should I stop all the meds I’m already on and wait for withdrawls to kick in before I apply the butran patch and then add the 30mgs of oxycodone for break through pain as needed.

    1. Hello, I as yourself have had my trials with options due to knee replacements, shoulder dislocations, curvature of my spine. After years of pain meds ranging in the beginning of 10mgs of Percocet to 30 mgs, trying, Covington, then, fentanyl. Finally, a friend who knew I wanted to quit this cycle of much abuse..as I was addicted, and taking way too much, only to go through withdrawals waiting for my refill, gave me a few suboxone 8/2 mgs to help me get past the initial anxiety, skin crawl, down and dirty kicking the meds. It was wonderful!!. No problem telling my doctor to stop my pain pills..He was very happy to do it. He couldn’t get my insurance to cover the suboxone..that where the problem began. My coverage only would allow belbuca film. Not helping..just not. I haven’t been able to sleep, anxiety, depression, and I had been using the suboxone for 33 days prior (my friend shared hers with me, yes I know the rules, but I owe her my sobriety) I am not ever going back to opioid addiction, but this is not a good day to day life at all. I have major depression and wonder why it is so easy for the insurance companies to cover strong doses of oxycodone..no problem, but not a proven solution that worked for me, to end the vicious cycle of addiction, that was my life. I still have pain, and now the addition of so much anxiety that I actually do forget the pain, maybe that is what they are hoping for. But, with all the substance abuse problems that are being discussed on the news, why make part of the solution so difficult to obtain, when it is available? And, btw, I had to wait over a week to get the belbuca as my pharmacy had to special order it! I get why so many of us pain sufferers get addicted as we become so tolerant to opioids, and remain so as the answer to quiting (suboxone) is difficult to obtain, and the alternative (belbuca) doesn’t hit the mark..At all. Thank you for listening and please respond if you are struggling also.

      1. Thank you for posting and being so upfront and honest about the addiction that comes with opiate Rx’s.
        I too have become addicted to the fentanyl & all going through exactly what you said: abusing them because of tolerance and addiction & can’t wait for the next Rx to be filled.
        I’ve talked to a friend about going onto Suboxone, but they said it’s just as hard to kick. Have you had this experience? I know you wrote this some time ago, but would like to know how you’re doing now?

    2. I have a 5 level thoracic spinal fusion and I was addicted to pain meds and have been on zubsolv or suboxone for a few years now. I also get acupuncture done every three weeks and it works wonders. Maybe look into acupuncture or other alternative medicine that can help. Good luck

    3. Dude, Ramsey,;’ you totally ruined a chance at a reply from the dr by replying to my post for NO reason

      No one cares about your history, we are here for general discussion about the Meds

      I was asking PHARMACOLOGICAL questions, so Dr, please revisit my post and answer if you dont mind

  103. I do not follow these forums diligently so if anyone wants to comment on what I write I would appreciate an email response at jjcardella@outlook.com. I will not go into extensive detail. I have had a horrible life; I have made many terrible mistakes. Not long after I turned 50 I began to wise up. My problems began with an addiction to sex which exposed me to any manner of other malignant activities. Around 1994 when I was 34 I was diagnosed with psoriatic arthritis, and later on upgraded to a combination of that and rheumatoid arthritis. It is all through my body (rt. shoulder, C2/C3, both hands/wrists, L3/L4, both knees, both feet and ankles. Over the years going to rheumatologists I ran the gamut of an extensive array of medications (NSAIDS, DSAIDS, feldene, azulfidine, indomethacin, cortisone injections, celebrex, mobic, Humira, and prednisone to name some of them. The biologics were touted as a miracle drug; I tried them twice both times doing nothing for me. Quite naturally I suffer from chronic pain, especially in the morning when I wake up. There were times I had to crawl on hands and knees to get from room to room; two friends, one on each shoulder, would have to walk me to the car. Around 1998 I asked my rheumatologist at the time “What about just some old fashioned pain killers?” I was lambasted being told, “Rheumatology does not believe in pain medication; if you go on them you will have to take them for the rest of your life!” On occasion I obtained medication for pain illegally; for PAIN, not to get high, because I was self employed and did not have medical insurance. On one occasion I was arrested for possession of a controlled substance; two 40mg oxycontin tablets. I received six months probation. During this time I got into a situation where my urine screen would come up positive for opiates so I asked my case manager to go to rehab just to stay out of jail. She asked me, “You really do not want to go to rehab do you?” She then went on to explain a program whereby the county provided clients with Suboxone. Mind you I was not regularly purchasing illegal narcotics, nor was I prescribed any, nor was I having a problem with any sort of addiction. I complied in order to stay out of jail, and was released some time after. In 2010 my rheumatologist said to me, “John, there is nothing more that rheumatology can do for you; you are at a point where you should consider seeing a pain management specialist if you want relief from the chronic pain you suffer from.” With the first pain doctor I would see him about five minutes; long enough for him to sign two prescriptions: one for 45mg of morphine sulfate ER 2x, and one for 15mg oxycodone IR 6x. This doctor was always complaining ab out interference from the DEA. Starting pain management was a real learning experience for me. Let me say people crawled out of the woodwork, asking me to share my medication. One guy said, “You mean you do not sell your medication?” I was appalled; of course I did not do this. I had no interest in being involved in illegal activity, nor in associating with anyone who was. Then the calls started. Someone tries to get medication from you, you decline, they know who your doctor is, they place a call to the practice making false allegations against you. One example, someone called and said I was selling my medication to my son. I do not have any children. After the office was called FIVE times I decided it would be in my best interest to see a different doctor rather than be dismissed and have negative information in my medical records. The pain doctor I see now comes in the exam room; very kind, friendly, generous, and intelligent. He is also a pathologist. He discusses what is causing the most pain. He runs you through range of motion tests. He finishes with trigger point injections. I am prescribed 15mg oxymorphone ER 2x, and 5mg oxymorphone IR 3x. In the eight years I have been doing pain management I have asked for a minor increase in dosage only two times. Opioid therapy has been a godsend in regards to my chronic pain, especially with the physician I see now and the oxymorphone. I like it because you do not need a lot of it for it to be effective. I have regular bowel movements. I do not take increasing amounts to achieve an altered state of consciousness. I arise early in the day, take my first dosage, and within minutes I am ready for my day. Unlike the days when I was on other medications that did not work, laying around doing nothing because it was so difficult to move, now I am able to take care of my house. I am able to take care of my animals. I am able to participate in the two hobbies I love so much: creating architectural drawings and painting with acrylics. I take my first dosage of pain medication around 5AM, usually starting the day with 10mg of the IR, and then my second and final dosage around 3PM (15mg ER and 5mg IR). I also suffer from paranoid personality disorder (or PPD). I do not want to go on SSRIs and/or anti psychotics, so I opt for 2mg of Xanax for the extreme anxiety and insomnia I suffer from. I take 1mg of Xanax around 7/8PM, and then the other 1mg before bed along with 15mg of Remeron. The regimen of medication I am on works very well for me. I do not experience problems; in fact, the quality of my life is improved. However, at the present time the political and otherwise climate is riddled with such excess negative stigma. The government would have the people believe that if you take opiates, if you are on opioid therapy, then you are an addict. They lump everyone into the same category. Every patient is an isolated case. I have so many challenges being prescribed both opiates and a benzodiazapine. I do NOT take them together. Several weeks ago my pain doctor wrote me a prescription for Belbuca really not telling anything about it. I researched it on my own, reviewing websites and the two books on opiates I have in my collection. I learned that buprenorphine is a partial agonist whereas oxymorphone is a full agonist that attach to the μ receptor. The partial agonist, buprenorphine, competes with the full agonist, oxymorphone, and always wins. In fact, not only does it always win, it can kick oxymorphone out of a μ receptor and take its place. The script of buprenorphine was written, “Take every 12 hours as needed for pain.” Belbuca is NOT an as needed medication; one must take it regularly. Furthermore, you cannot take buprenorphine and oxymorphone together. The oxymorphone is wasted. So far I only was written one prescription for Belbuca, but should it continue I cannot see where my insurance would cover both medications. It just would not make sense to be prescribed both at the same time. Now it matters not to me whether I take Belbuca or oxymorphone; I just want the “luxury” of being able to get out of bed in the morning, manage day to day activities, and not be grounded because I cannot do anything due to chronic pain. When I took the Belbuca and oxymorphone together it seemed there was no improvement; if anything I was in more pain than usual. I thought I should give the Belbuca a fair shake after reading about it and how it worked. So I took it along for several days. It did nothing for pain. In comparison to the oxymorphone it is an inferior medication in my opinion. I feel I am between a rock and a hard place. My doctor mentioned transitioning his patients from whatever they currently take to Belbuca. If he insisted, deciding he was unwilling to continue to prescribe opiates like oxymorphone, morphine sulfate, and so on, and became adamant all he would write is Belbuca I would be stuck with it, or maybe a higher dosage would work. With the way the climate is right now it would be moot to try and transfer to a different practice as I seriously doubt pain management specialists are going to write full agonist opiates to new patients, regardless of their past history. I like my current doctor; he is legit. I have no desire to go to a practice that is merely a “pill mill.” The doctor I see right now cares. He manages his practice professionally – correctly. He doesn’t just sign prescriptions. I am wondering just what is the deal with this Belbuca. How is it that what was once the pain medication my veterinarian administered to my cats, and the medication used to treat opiate addicted patients now all of a sudden has become the wonder drug for pain? I do not see it. I feel I gave it a fair chance. It is difficult to settle for buprenorphine once you have enjoyed the improved quality of life made possible by oxymorphone, a small daily dosage, no desire to want to take more for some effect other than elimination of pain. It is like I have been driving a 2017 Cadillac CTS, and then all of a sudden it is taken away from me and I am told now I have to drive a 1989 Chevy Cavalier with 250,000 miles. What is really going on? Can anyone tell me? Does anyone have any advice? I feel like the medical field has information that they withhold from patients; that they deliberately pull tricks on patients. For example, at one time I was prescribed 4mg of Xanax by my psychiatrist. Now I will be honest, 4mg a day was more than enough, and most of the time I did not need that much. Then it was dropped to 3mg a day which was an adequate amount. It enabled me to have a Xanax during the day if I needed it for anxiety (I travel with two older women; one 66, the other 81 – sometimes a simple doctor’s appointment for them turns into a six hour plus affair). Then 2mg before bed was perfect. Then it was dropped to 2mg per day. This amount is challenging because realistically most of the time I need 2mg before bed due to insomnia and occasion night terrors. It does not allow for 1mg during the day if I would happen to need it (on rare occasion). For all intents and purposes I rarely take oxymorphone and alprazolam together. When I was dropped to 2mg a day I was told by my psychiatrist, “The DEA has a new rule. If you are prescribed opiate pain medication, then the maximum amount of alprazolam we are permitted to prescribe is 2mg a day.” This is a crock of sh**. It is the Drug ENFORCEMENT Agency; they are a government agency in place to ENFORCE the laws. They are not a legislative branch of the government. They go into physician’s practices, especially those in pain management, or psychiatrists who prescribe benzodiazapines. Mostly, any practice that regularly prescribes Schedule II narcotics. They bully doctors. They make suggestions and recommendations, and those physicians who do not comply can expect more frequent visits from the DEA, and have their records more closely scrutinized by the DEA. I have searched websites extensively. I want to know what is really going on, but I can never find answers to my questions/concerns, or the type of information I am interested in knowing about. And I am sure a lot of what goes on in my mind at least is somewhat due to the PPD I suffer from. For example, I would like to know if the DEA provides practices with lists of patients who maybe were in some kind of trouble at some point in time. Does the DEA go into a practice requesting a list of patients and what they are currently prescribed? Then do they come back and hand the doctor the list of their patients with information about any patient who has ever been convicted of a crime involving drugs. Illegal sales for example. I have a pretty ugly past; many things I am not proud of. I have one conviction for possession of a controlled substance; that was sometime around the year 2005, or twelve years ago. But today I am an honest, law-abiding citizen. I do not associate with people who abuse drugs, or sell drugs. I want nothing to do with these type of people. I just want to live my life pain free in peace. I just want the right to be prescribed a medication that improves the quality of my life by greatly reducing the chronic pain I suffer from each day. And I want to do all of this legally, legitimately, and ethically. I do not believe that is asking too much. Like I tell people, “I am just a simple, poor, but happy guy.” Opioid therapy has played a key role in making life tolerable. What of the honest law-abiding patient who takes their pain medication responsibly as prescribed; and is given access to the best possible pain medication that their insurance will cover? Do we not deserve this? How do we get correct information? How do we stay up to date, and be informed about just exactly what it is the government, the DEA, and physician’s practices are doing. Do we not have a right to know? Do we deserve to be tricked into being forced to take an inferior medication like Belbuca? Or even a biologic like Humira that I took twice and found to be completely useless, not to mention the plethora of possible side effects, on of which is cancer? I am done with my rant. If you endured my writing this far I sincerely and most humbly thank you.

    1. Well, I can give you some I insight as to what is going on. It is all about the money! It is not about your pain. You are a guinea pig to them. Trendy doctors who want you to believe that they are helping you. The only thing they are helping is their bank accounts. Look at how much these new medications cost. Just like when oxycontin​ was first introduced. Look at what they are pushing. $$$$$$$$$$$$$$$$$$$$$$$$ I have not met an honest physician yet. Very sad but true.

    2. Very nice sharing your story. I have chronic pain, have been on buprenorphine sublingual tablets for 12 years, I’m only 31. They want to switch me to Belbuca, I’m nervous because I have a very high tolerance. Hopefully it works as well.

    3. Hello
      I read your rant and I can relate to so much of it. Those on pain meds such as oxycodone and take them as prescribed are not addicts. We are in that unfortunate situation requiring opiates. We need to speak up and let our lawmakers know that we need these opiods.

      Jerry

  104. I am wearing a butrans 20 patch for a year now. This is the maximum dosage I can get. It has been pretty effective for my lower spine pain. However, my pain is getting worse lately when I have to supplement with hydromorphone 2mg q8h. Can I add a Butran 5 to my regimen to make 25 mcg/h instead? In Europe, they have buprenorphine transdermal 35 to 70 mcg/h and QT prolongation isn’t a big concern.

  105. I have a very important ? And can’t seem ton find the answer anywhere and am
    Suffering greatly because of it. First off let me just say I am a gastric bypass patients of 6 years…… About 4 years ago I starts have g tremendous paun in NY neck ans ago I idea and now also my back. I was just recently sent to a new PM Dr for a 2nd or actually 3rd opinion. My previous PM Dr had me on Belbucca with Nucynta for break-thru pain….. It was work I g fairly well, when I saw this new Dr he told me that because of the Belbucca that the nucynta wouldn’t work and if I thought I was getting any relief it was a placebo affect! Is this true? He proceeds to put me on suboxen 8/2 sublingual strips ( not even trying me what the true nature of what this was used for and said the wasn’t much more he could do for me. I am getting little to no relief and have nothing Dr break thru, when I saw him the next month again he said that I was on the highest figure possible and basically to bad I can’t hello you, things time the RX he wrote was fir a sublingual pill, which they ask the research i can find says that because of the way I metabolize medications I am getting even less of the bupropprion than with the strip and basically the naloxene is bull and void by the time it gets into my system! I need help and fast, I can’t seem to even be able to get return calls from his practice St this point and I am so miserable! And also fear that look it’s most i have now been labeled as a drug seeker! UGH!!!! So what I really need to know is what your opinion is on the way my body metabolizes these or any medications fir to my bypass and can the belbuca and nucynta be used together and work? I’ve also read that suboxene is a big no no fir gastric patients! Im terrified of withdrawal if any kind since I had a horrible experience with CymBalta about 8 years ago!
    PLEASE? ANY AND ALL INFO OR HELP WOULD BE GREATLY APPRECIATED ASAP
    THANK YOU,
    Billi

  106. I have a question. I am a recovering alcoholic have been clean for 20 yrs. I had an accident and due to that found I also have RA OP OA AND DDD. I’ve been very upfront with my pain management doctors and very careful about what they prescribe me. I also have sever anxiety so wanted to make sure no drug combinations could cause me harm. My doctor had me on fentenol which I begged him to take me off it caused me to have to have rectosil surgery. Finally I’ve been put back on my original meds 1 10 mg norco 2x a day. I was doing okay but by 3 pm I was back in bed and couldn’t get up due to the pain I’ve have a lamanectomy from c3-c7 and need lower back surgery as well. My quality of life has been nil to say the least. Last month he added belbuca 150 mg 2 x a day. Because I am so scared how it will interact with my anxiety meds I have eased into this. Taking it only once a day and slowly taking my other meds because I am scared I have not yet added the second dose but have all my other meds on board showing no difficulties. So today I’m going to try the second one at night. My fear is that it will interfere with my night time meds so I completely have stopped talking them other than my xanax 2 mg 3x a day and my robaxin
    Do you think it’s safe to take the second dose at night?

  107. What is the equivalent to other pain medications when it comes to 450 mcg of Belbucca, two times a day? Actually if you could give me the equivalency for all Belbucca 450+ that would be excellent!

  108. I have been taking suboxone off label for pain for over a year now. I’m very sensitive to narcotic drugs & had terrible experiences on every pill I was given to try. My doctor had me fill out a form about taking an off label drug for pain prior to starting suboxone. At my last visit she told me about Belbuca and that she may be able to get my insurance to cover the medication. Due to so many fails on other meds. suboxone has worked great for my pain and I have no side effects. I’m scared to try and make the change. I don’t understand a lot of the “doctor” talk. Will i feel the same on belbuca as I do suboxone? I would love to save money, but living as close to pain free as I ever will on suboxone, it worries me to try something new. thank you

    1. Sam, when there are name-brand meds with no generics, try going to their official pages and seeing if they have savings coupons. Most do and they can save you a ton ton ton of money.

      Regarding your question, you just have to find the equivalency dosage of Suboxone to this. For that, ask your doctor and/or do some research online. I’m sure if it doesn’t help you as much, your doc will put you on your current med again.

      Best best best of luck! Check those sites, they almost always offer savings coupons!

  109. I see lots of posts on here about rescue meds (IR meds like Percocet, Norco, Morphine, etc) no time working with the Butrans patch and I feel that needs further discussion. I know many folks who take breakthrough meds with Butrans and have no problem. From 10mcg to 20mcg, from 5mg Percocet to 30mg Morphine Sulphate IR, I’ve heard d and know of people who still get relief from them. Confused?!

    1. Kyle,

      There are always some unoccupied opioid receptors, especially at lower doses of buprenorphine. For that reaons, there can be some benefit at the doses you listed.

      1. Thank you for the reply! Might I ask, and if you don’t know it’s okay, but what is the difference of 20mcg/hr of Butrans and let’s say 2mg suboxone a day? To my understanding, the entire dosage of the Butrans 20mcg patch (meaning 20mcg/hr*24*7) is 8mgs, correct?

        Also, with the opioid laws changing, it’s really hard for us patients in some areas to get relief. For example, my pain doc booted me because I told him I wanted Percocet instead of Norco. I’ve passed all drug tests, begged him to send me a referral to PT, pain desensitization counseling, and 2 more provedure injections before we try the nerve stimulator. But he literally booted me! Now no one will take me as a patient. However, my PCP loves me and we have a great relationship. He knows me well enough to know that I didn’t abuse even one pill or do anything to compromise the safety and necessity of me needing pain meds. Do you think a PCP would be receptive to Rxing this?

        I know such an answer depends on different variants but in particular it depends ON THE DOCTOR but in your knowledge, is it commonly done by PCPs?

  110. Dear Dr Fubin,
    Thank you for educating me regarding Belbuca. I suffer from chronic Paine due to RSD/CRPS. I became opiate tolerant after years of pain management. I was then introduced to suboxone. It not only helped my chronic pain better then every other opiat, nerve block, etc.. I was actually able to resume a productive life.
    Can you offer any advise on how to speak to my primary doctor to prescribe this medicine for me.
    I’ve had 3 major surgeries last year and once I healed from them and was ready to continue suboxone he was at his patient limit.
    It’s been since 3/16 I’ve had no pain control and I rarely have good days. I can’t continue like this and no one will help me with Suboxone because I’m not opiate dependent.
    Please help me.
    Kindly,
    Tied of being tired

    1. Tiffany
      It may be better to ask for Butrans or Belbuca as they are primarily indicated for those with moderate-severe pain. Suboxone and subutex are primarily indicated for addiction treatment and in fact is not labeled by the FDA to help with moderate-severe pain. It is used off-label obviously but some states (Tennessee, Virginia) have banned allowing it for off-label use (which is pathetic, especially banning suboxone). For this reason, docs may be iffy.

      Another suggestion is you try seeing pain management. While regular PCP’s SHOULD be able to give pain meds for even chronic pain and while they technically are allowed to, the CDC discourages opioid Rxing except for acute pain by PCP’s. Doctors still can but it’s very rare due to paranoia and it really depends on the state too.

      Also if you are in a lot of pain, while suboxone may be the most effective for you, you can ask your PCP about Tramadol, Tylenol 3 with codeine, or Tylenol 4. If you are taking an SSRI, Codeine is usually de-potentiated by 50%. You might want to mention that to your doc as Tylenol 4 would be your best bet. Tramadol also loses its potency by 50% if taking an SSRI. (Note- not all SSRI’s but for both codeine and Tramadol, most.) You could ask for those or of course you may still ask for Norco, Percocet, etc. If you plan to re-attend pain management but can’t be fit in right away, your doctor will likely not have a problem writing a one or two time Rx until you can be seen. Believe me, even Tylenol 3 is *much better* than nothing. You can also ask for Rx NSAIDS like Diclofenac(Voltaren) or Nabumetone. They don’t help me at all but are better than nothing. And they’re no opioid but still better than nothing.

      I hope you find relief!
      -kyle

      1. Hi Kyle,
        Update: I’ve been put on Belbuca 300 mcg every 12 hrs and lyrica 150 mg once daily. It seems to be helping to some degree. I’m scheduled for surgery in late September which requires 5 hours under anesthesia. I’m now facing the double edge sword… without appropriate pain control I can’t physically gain enough strength to undergo such surgery . Then again, I’m worried about my resceptors being unable to accept the acute pain medication I will require. I will be speaking with my surgeon about this . I certainly want to speak directly to the anesthesiaologist as well.The first surgery I underwent was the worse pain I’ve every had in my life… At that time I stopped suboxone 5 days prior. I was post- op on the highest amount of morphine and oral opiate medicine as well. I couldn’t believe the amount of pain I was in!!! Needless to say, I’m worried. Any thoughts?
        Thanks

    2. Dear Dr Fudin,
      My pain management Dr. prescribed me 300mcg of Belbuca. At first I felt some relief, then the cycle started to repeat. The office called me and I told them. I asked if they would call in Bupranorphine tablet. Instead the called in nucynta 50 mg. The first dose It felt promising then I became very groggy and slept a full 8 hours. I woke up with the worst rash. The pharmacist told me to take Benadryl, and I did. They next day (today) still itchy and very shakey/ anxious feeling. I so badly want this to work but, the anxiety & sever rash has me concerned. Looking back at all the medication I’ve tried ,the only success I had was on suboxone. Again , I’m not opiate dependent and I feel my Dr.” may be “avoiding prescribing me this off label. I’m not 100% sure about that statement. I would really like to try the oral buprinorphine pill that appears to be stronger. I now understand mcg verses mg…
      in any case, would you be willing to speak to him regarding this matter? All this trying different medications is putting me over the edge. What’s the real problem here? I know what has worked for me in the past… I’m tired of being tired and Ginny pigging all these medicines.
      Please advise.
      Thank You,
      Tiffany

  111. I was put on suboxone bc I talked to my psychiatrist about the withdrawal I was having as I tried and tried to stop the opioid medication taken for chronic neuropathic pain (9 1/2 years). I was worried bc I saw these medications cause devastation in so many families. I couldn’t get off and felt like I was going crazy. I was diagnosed as opioid dependent, my Dr applauding me for wanting to stop the medication before dependency turned into addiction .I was surprised that it helped with my neuropathic pain better than the previous pain meds (opioids). I am also prescribed lyrica which I was on during pain management. Adding suboxone to lyrica helped my neuropathy tremendously. I was also told I had developed opioid-induced hyperalgesia.

    I tapered the suboxone, but even lowering the dose kept pain under control. I tried tapering off only to have my pain come back full force once I got below 2mgs. Some days were worse than others, of course.

    Having been on suboxone, I couldn’t find a Dr who treats pain to treat me. I feel I had been ‘red-flagged’ bc of the suboxone for opioid dependency. My suboxone Dr and I decided that low dose suboxone (2mg) taken in divided doses could be prescribed to ”maintain recovery for dependence and manage chronic pain”, especially since even if I could find a Dr to treat me I would never want other opioids. Belbuca looked promising but when I asked my Dr who treats my spinal arthritis he hadn’t heard of it and wouldn’t prescribe it. My insurance wouldn’t have covered it anyway so $800+ / month was out of the question.

    Now my grandchildren have been removed from my daughter’s custody. When I offered to let them live with (they had already been living with me and their mom wasn’t , nor allowed to be around) the children’s services excluded me for a placement home due to the fact that I’m on suboxone. I was told that suboxone isn’tused for pain management. I tried to explain the difference between dependency and addiction but they still label me a recovering addict.

    I have sought information proving that suboxone used for an opioid dependent person who still lives in chronic pain is a viable option. I’m also looking for information showing that patients who have been treated by suboxone are shunned by other drs. This is happening so much, I have found. It’s very disturbing bc most people who have received ling term treatment for chronic pain do develop opioid dependency. Opioid dependency often leads to addiction, but not always

    1. Hi Mary,
      I stumbled across this site while researching other options to treat my chronic pain from rsd/ crps. I’ve gone through pain management to only realize i built such a tolerance to opiates that they were no longer help but instead hindering. I too feel “red flagged “!!! No suboxone dr will treat me for pain only opiate dependency. I was placed on suboxon to help me get off opiates. That’s the only medicine that I was ever on that controlled my pain. After stopping suboxone for several surgeries, my sub Dr will not take me back because I’m not opiat dependant. Ugh!
      Where you able to find a dr to prescribe you Belbuca? If so how are you doing with your pain? I certainly hope you were able to get help. Chronic pain is just awful and I feel for everyone who suffers from it.
      Thank you,
      Tiffany

        1. Dr Fudin,
          Thank you for your quick reply. I’d also like to state, my primary Dr is not the Same Dr who started me on suboxone.
          Have a nice day,
          Tiffany

    2. Mary, if the custody issue is a really big issue for you, I’d fight it. Whoever gave you Suboxone in the past, ask that they write a letter stating it was for the treatment of pain and not abuse. Similarly, when seeking other pain management practices, ask that when they send your medical records over that it clearly states that you were given Suboxone for pain. If they don’t ask for your medical record/they don’t have it for some reason, ask that they still write a letter indicating why you were on Suboxone.

      While you took Suboxone for pain and weren’t abusing, there are lots of people who have abused opioids/taken illegally due to being in pain, not for seeking a high. For these folks, getting pain treatment can be nearly impossible. I live in Texas where we are mostly spared from the opioid epidemic and doctors licensed to prescribe Suboxone are very rare. The issue of folks getting in trouble and being unable to be accepted by pain management has been a huge problem here. So just know that while your situation is much different, you are not alone! I’ve been discharged for “pseudo addiction” which many doctors don’t seem to understand. Addiction is abusing meds to get hifh. Pseudo addiction is possibly misusing your meds on accident or even on purpose but by “misuse” I don’t mean taking 10 at one time. If they are prescribed 4 of a certain med per day and they have to take 5 repeatedly, that’s what I mean! I wish doctors would understand the difference and distinguish it moreso. Many do, but lately (since the newer opioid prescribing laws have come out) it’s been rare. You’re not alone in being able to find relief! I hope you get your grandkids back! And I hope that one day suboxone becomes the golden standard for first-line opioid options.

    3. Mary,

      What has happened to your grandchildren is appropriate appalling!

      I am in Oregon, a state where pain management is bad. I moved back to Oregon after being gone for six years and most recently living in Nevada with decent pain control (a good day was a 3 – 4 and active) with morphine ER & Percocet 10/325. I never took one extra pill or took one early and always had pills leftover at the end of the month! I was careful, I had minimal dose days and maximum dose days. I varied doses by how bad my pain was and strenuous the planned activity was. Still though, it true my body did develop a dependency.

      It took me 5 months to get a PCP and then another two weeks to see a pain doctor who walked out in the middle of an appointment refusing to treatment me. Because I had run out of pain meds. I had bedridden for 3 months and he did that. Incredible.

      I went through terrible stomach aches and headaches for 4 months from the morphine stopping. I did not want to do that with the Percocet so Iooked up how to taper off. Everything I read said to do it under doctor’s care, but I did not have a doctor willing to help me, unless I checked myself in as an addict, not what I am (and numerous doctors have said so as well). There however, I learned about Suboxone.

      Okay, I am sorry I went on a rant. At this point I am ready to move back to Nevada, but I would be alone.

      My next pain doctor doctor wanted to prescribe Suboxone. Because I already knew of it and the FACT it is NOT FDA approved for pain management I said no. I told him I did not want Suboxone in medical record, insurance record, or police/DEA record! He immediately backed off. He did prescribe a tiny dose of Percocet, 16% of a previous active day dose, which has got me out of bed, but not doing anything except for 20 to 30 minutes once a day. Whoopie – not.

      Now he wants to prescribe burprenorphine. I do not know which form. One of my concerns is ending up in your type of situation somewhere down the road.

      Mary, if you got affidavits from two of your doctors stating they have not seen indications of addiction and why you are prescribed Suboxone rather than xyz, maybe that would help with you getting custody of your grandchildren back.

      Doctors do not like to take the time to do this stuff. Type up something simple take it to an appointment and see what the doctor says . When you have two then ask a lawyer or legal aid, a children’s advocacy group. Many years ago I was a leader in adoption reform, for all the good it did not do for the birth-family and and children, but it is worth a try.

      Buprenorphine, I do know? What is wrong with what I was taking before (from Oregon to Hawaii to Nevada) for twelve years and never abused or misused it, why do I have to change now? Is it going to give me more pain relief, not by what I read here. I do not think it will equal it. If a maximum dose patch is equal to 80 mg of ER morphine in 24 hours, my maximum was 90 mg morphine ER plus 50/1625 mg Percocet in 24 hours, but not every day and not more than two days in a row.

      I guess I should mention, I do not get euphoric on this, nor do I want to. I just want enough pain relief to do things a d not be labeled medically or legally an addict, or mess with future medical or dental procedures. I need presently need a knee replacement, dental work, and lasic eye surgery, but I cannot do any of that until I have the back pain under control and the prescription problem resolved.

      Sorry, I am on a rant again.

      1. I am sorry Jana. Stupid auto-correct! I do not think what happened to your your grandchildren was appropriate! If you look again the next word is appalling.

        There are several other errors, but none that are hurtful.

        Keying on a Kindle is frustrating.

        Warmly,
        gs

  112. Dear Doctor Fudin….I am looking for a simple conversion from Suboxone to Belbuca. I am currently on Subs. 8/2 three times a day for pain mgt. off label. Have heard of Belbuca and would like to be well informed on this new med. when I next see my dr.. I’ve read that there are doses up to 900mcg. and would like to know which of the several dosage options would equal 24mg. of Suboxone daily

    Sincerely, Joe Hetzer

      1. None of this is okay. Your medical provider and you should have a very clear plan of how to approach this. Haphazardly cutting or adjusting dosage forms in ways other than intended is a recipe for disaster.

  113. Hello Dr’s!

    I broke my l2 last fall. Was just taken off Percocet. And am now on 10mcg patch. For 7 days at a time. On my 4th. Withdrawals aren’t too bad yet. Am I correct in believing that these Butran patches will help for opiate withdrawal?

    Thanks, Charlene
    Baton Rouge

  114. I been on 10 milligram oxycodone for a year previously I was on 7.5 milligrams of Oxycodone I took that for 5 years my pain management dr just started me on buprenorphine 75 bcc and I tell u I hate it and feel like the oxycodone works better my pain still there with the buprenorphine and I been doubling sometimes tripling my dose to get out of pain I don’t feel like it’s a effective pain management medication

    1. Hi Ed, I’ve been on almost all pain meds, 2 spine surgeries, then car accident, i first found butrans patch I didn’t get relief until I reached 20 mcg worn on the skin for 7 days, I didn’t get 100 percent relief until I got to 20 mcg, but I was badly blistered by the patch, I even moved to a warm climate for relief. Through research I found belbuca. My pm dr didn’t know the medication, he only would give me 37.5 mcg, no help, I’m in the process of trying to get him to go to 400 mcg. It’s the only medication that worked for me! But try, I know everyone is different and everyone has different meds that work, I was on 80 mg oxycodone and still in pain, I was very concerned about addiction, then they cut you off with rehab or worse, I hope you get safe relief, whatever works for you, I sympathize

  115. It is certainly challenging to manage patients with opioid addiction on buprenorphine maintenance who are coming up on elective surgery. For those who can receive a regional block and are expected to have no more than moderate pain I typically continued the buprenorphine product and used tapentadol IR for analgesia with success. For those expected to have significant pain as a result of the surgery I did what might be called a fentanyl bridge. Thinking that most of the buprenorphine has peeled off the receptors in 4 days, I had patients come in 4 days before the surgery date. Buprenorphine is stopped at that time and a box of 5 fentanyl patches 12 mcg was prescribed. One 12 mcg patch is placed. If there is significant pain in 2 days, the first patch was removed and 2 patches placed at that time. I did not place 2 patches initially even with pain because in that transition I did not want risk of fentanyl overdose as the fentanyl slowly replaced the buprenorphine as it moved off the receptors. On day 4 inception and maintenance of surgery was easier and the remaining patches could be used for an analgesic foundation. For IR I tried to use tapentadol as there appears to be much lower addiction liability compared to “standard” opioids.
    Throughout all this I engaged the patient’s 12 step sponsor (if there was one) to communicate with the patient in the postop period to address valid need for prn postop opioid since no one better understands the validity of the claims made by a person with addiction than one’s sponsor. This approach seemed to work well and avoided relapse.
    BTW – buprenorphine was originally introduced as an analgesic before Jasinski et al recognized its potential for opioid addition.
    Rolly G, Versichelen L. First experience with new analgesic drug: buprenorphine. Acta Anaesthesiol Belg. 1976;27 suppl:134-42.
    Jasinski DR, Pevnick JS, Griffith JD. Human pharmacology and abuse potential of the analgesic buprenorphine: a potential agent for treating narcotic addiction. Arch Gen Psychiatry. 1978;35(4):501-16.

  116. You are wrong about Buprenorphine getting its start in treatment for addiction. In Europe and England it was used for the treatment of pain and then America started looking into it.

  117. What are your thoughts on the fentanyl patch?
    I have seen multiple patients misuse/abuse the patch…chew it..freeze it..cook it. Regardless of how often fentanyl and heroine are often in the same sentence on the news regarding either abuse, death, or drug busts by the DEA, it is still a preferred status medication on multiple insurance plans, while Belbuca remains either restricted, not covered or empirically rejected by multiple commercial plans, majority of Medicare Plans and almost every Medicaid plan. What can be done by either physicians or patients, to achieve having their prescription of Belbuca covered by their prescription drug plan

  118. I have a question…when Suboxone and Subutex is prescribed for pain, by a pain management Doctor, you have the same insurance and it was being covered, why would they quit coverage all of a sudden just because of the XDEA #. It doesn’t make sense, however insurance will cover Belbuca.? I had to quit taking the Suboxone because it was so expensive. The alternative was Subutex, it wasn’t covered at all even with prior authorization, it too is pricey even as the generic, but Belbuca was covered. They’re all bupernorphine and it doesn’t make sense.? I was hoping so much the Belbuca would be a great alternative due to the cost efficiency, however when taking it BID after 3-4 hours my pain would come back as if I was taking nothing at all. How is this possible? Thank you in advance for your time and understanding!!

  119. I just finished reviewing your response for KOR MOA
    Thank you for all your very thoughtful and comprehensive responses

    There are some studies that seem to indicate the KOR agonists opioids (opposite to buprenorpine) as also having a beneficial effect on analgesia and MOR tolerance

  120. Thanks for your prompt response regarding my questions, and here are a few more:
    Some of the literature that I reviewed actually implicates Cytochrome CYP2B6 as the most important variable for methadone metabolism, and may in fact contribute to its cardiac toxicity.
    Does buprenorphine or other medications that may cause prolonged QTc have any metaboiism through 2B6?
    The FDA has recently added additional warning to all opioids including the risk of serotonin syndrome
    Is there any binding to 5HT receptors by buprenorphine or any documented cases for this adverse event?
    Please explain any additional clinical implications of buprenorphine’s kappa antagonist effects.

    1. Dr. Hoffberg; I can smell a good teacher miles away. Thank you for encouraging this dialogue!

      As you mentioned, 2B6 is an important metabolic enzyme to consider with methadone, specifically with regard to the S enantiomer. S-methadone is metabolized by CYP2B6 to the inactive EDDP (2-ethylidene-1,5-dimethyl-3,3-diphenylpyrrolidine). Although the EDDP has no opioid activity, accumulation of the S enantiomer is associated with torsades de pointes and sudden death. CYP 2B6 is not an enzyme associated with buprenorphine metabolism. Therefore a poor CYP2B6 phenotype patient identified as such by pharmacogenetic testing, should not be placed on methadone. A great methadone alternative for managing pain, if it wasn’t cost prohibitive is levorphanol. Levorphanol has a similar m/a, avoids serotonin, has NE activity, blocks NMDA, is a great opioid, and also has kappa agonist properties. (See Gudin, J, Fudin J. and Nalamachu S. Levorphanol use: past, present and future. Postgraduate Medicine. 2016 January; 128(1): 46-53.) If you don’t have access, email me for the PDF if you have interest.

      Regarding other opioids that involve CYP 2B6, the active tramadol M1 metabolite (O-desmethyl-tramadol) contributes to more analgesia than the parent compound, the combination of which is likely enhanced by minimal NE reuptake inhibition, but first pass metabolism is required prior to any significant opioid analgesia. Further metabolism of the M1 metabolite occurs via N-demethylation to N-desmethyl-tramadol (M2), which is ultimately catalyzed by CYP2B6 and CYP3A4, however a poor CYP2B6 metabolizer in this situation, unlike methadone, is not dangerous.

      Regarding FDAs recent additional warnings to all opioids including the risk of serotonin syndrome, some of that is unfounded. Meperidine certainly does have an effect on serotonin, as does tramadol both of which could cause serotonin syndrome especially when combined with other agents that have such activity. Buprenorphine has minimal activity on serotonin and I will say that in the last three decades of my career, I have never seen a serotonin issue with buprenorphine.

      Tapentadol has always carried the serotonin warning most probably because of its similarity to tramadol in terms of chemistry, and although both are phenylpropyl amines, only tramadol has serotonin activity. Tapentadol only undergoes phase II metabolism (avoiding the CYP system), it has superior opioid activity above and beyond tramadol, and it only blocks reuptake of NE but not serotonin. There is a nice comparative summary on another of my blogs at Tapentadol; A Unique & Rational Opioid Option for Neuropathic Pain. I also covered tapentadol in much more detail just last month in Practical Pain Management linked at Is Tapentadol a Glorified Tramadol?.

      Regarding your question on the specific pharmacology of buprenorphine kappa antagonist activity, that I’m going to hand off to my mentees Joe and Jacqueline because I want to be certain they are on top of it!

      Cheers Dr. Hoffberg!

      1. Can a primary care physician prescribe Butrans Patches or Pain Management? My husband has severe peripheral neuropathy and his legs and feet. He’s diabetic and has end-stage liver disease. He was in such excruciating pain his friend had one patch from a heart operation that he gave to my husband. The patch was a miracle miracle he walked for seven days. I don’t know why a doctor won’t prescribe him this patch for what time he has left it’s sad both our quality of life has gone to nothing . if you could help with any advice I’d appreciate it. we live in St Louis Missouri. Today is the last day the seventh thing or is patch and or both he’s a musician and drummer can’t even walk

          1. It doesnt work for pain it made it worse. It blocked my percocets from working and my pain was realy bad there should be laws againts this.

      2. Can a primary care physician prescribe Butrans Patches or Pain Management? My husband has severe peripheral neuropathy and his legs and feet. He’s diabetic and has end-stage liver disease. He was in such excruciating pain his friend had one patch from a heart operation that he gave to my husband. The patch was a miracle he walked for seven days. I don’t know why a doctor won’t prescribe him this patch for what time he has left it’s sad both our quality of life has gone to nothing . if you could help with any advice I’d appreciate it. we live in St Louis Missouri. Today is the last day of his 7 days, 10 mg. He’s now an unemployed professional drummer.and we both feel hopeless.

      3. This Butran patchs is FDA approved for chronic pain. The only thing im addicted to is trying to live pain free. The fda is cracking down on doctors because of so many overdoses from the abusers and we have to suffer for it.this is a opioid blocker it blocked my percocets from working. Causeing me to be in so much pain loseing time from my job stilling my life away GOD please help us who are in real pain.

    2. Hello Dr. Hoffberg,

      Thank you for the great questions! Hopefully this response provides some helpful insight.

      One problem we’ve noticed with the Butrans patch in particular is the development of rash/itching at the patch site. This might be related to the kappa opioid receptor (KOR) antagonism as has been demonstrated in mice (1,2).
      Buprenorphine has demonstrated treatment potential for major depressive disorder (MDD) in patients with an inadequate response to antidepressants. Buprenorphine combined with samidorphan, a potent mu-opioid antagonist, resulted in improvements in MDD (3). Assuming samidorphan was blocking buprenorphine associated mu-opioid activity, it is reasonable to believe the antidepressant effects may be due to KOR antagonism.
      In an assessment of buprenorphine’s antidepressant effect in mice, similar antidepressant affects likely due to KOR antagonism were observed (4). Unpredictable chronic mild stress was applied to the mice, which resulted in reduced light side time in a light/dark box, increased immobility in the forced swim test, and induced region-specific alterations of mRNA expression. These effects were normalized with buprenorphine, but not in mice without the genes responsible for KOR expression. These findings are additional support for the implication of the KOR as an important mediator of psychological disorders as availability of KOR was found to be closely associated with the severity of loss/dysphoric symptoms (5).
      The KOR has also been implicated in the area of drug dependence. The mechanism for this is related to dynorphin, an endogenous ligand for the KOR that is released in response to both reward and stress. Binding of dynorphin to the KOR reduces dopamine release, resulting in dysphoria/anhedonia. KOR antagonists have shown to attenuate problematic motivational and emotional states related to stress and drug withdrawal. A high-affinity short acting KOR antagonist was tested in the setting of nicotine withdrawal and demonstrated reductions in both physical and behavioral manifestations of nicotine withdrawal in mice. The referenced article also discusses the positive findings of longer-acting KOR antagonists (6).

      1. Dimattio, et al. Zylkophin, a short-acting kappa opioid antagonist, induces scratching in mice. Meuroosci Lett. 2014 Mar 20;563:155-9.
      2. Kamei J, Nagase H. Norbinaltorphimine, a selective kappa-opioid receptor antagonist, induces an itch-associated response in mice. Eur J Pharmacol. 2001 Apr 20;418(1-2):141-5.
      3. Ehrlich, et al. Evaluation of opioid modulation in major depressive disorder. Neuropsychopharmacology. 2015 May; 40(6): 1448–1455.
      4. Falcon E, et al. Antidepressant-like effects of buprenorphine are mediated by kappa opioid receptors. Neuropsychopharmacology. accepted article preview 16 March 2016.
      5. Pietrzak RH et al. Association of in vivo k-opioid receptor availability and the transdiagnostic dimensional expression of trauma-related psychopathology. JAMA Psychiatry. 2014;71(11):1262-1270.
      6. Jackson KJ et al. Effects of orally-bioavailable short-acting kappa opioid receptor-selective antagonist LY2456302 on nicotine withdrawal in mice. Neuropharmacology. 2015 Oct;97:270-4.

        1. Yes! Thanks

          This is directly in support of what I just asked the good Dr a few days ago….

          Is there any indication that there is continued research in this direction?

          Meaning, are researchers and/or , probably more importantly, the pharmaceutical industry looking into buprenorphine for psychiatric use??

          ALSO Dr Jeff,, at what dose is this antidepressant effect observed?

          Thanks Dr Jeff

          1. It’s difficult to know what dose of buprenorphine will exhibit antidepressant effects because there aren’t trials with thousands of patients. But, technically any doses of Belbuca at 75mcg twice daily or higher, or an equivalent of another product could help.

  121. This topic is well balanced, and addresses the concerns of QTc prolongation as buprenorphine dosages are increased for pain management.
    Please let me know your recommendations regarding when to obtain baseline or interval QTc assessments with ECG for all buprenorphine products.
    Please give a perspective of the magnitude of these changes compared to methadone
    Please let me know which Cyt p450 metabolism pathways most likely contributes to the QTc prolongation
    I believe that one major exception to the recently published CDC guidelines (applied to primary care providers for management of chronic noncancer pain in adults) is that buprenorphine products be positioned as a long acting opioid for the initiation of treatment (and not necessarily requiring short acting opioids to be used first) in selected patients in chronic pain with FDA criteria .

    1. Dr. Hoffberg thank you for your comments and response and below you will find the answers to your questions:

      (1) Please let me know your recommendations regarding when to obtain baseline or interval QTc assessments with ECG for all buprenorphine products: there is no distinct recommendation as to when obtain an ECG for buprenorphine patients. For methadone the standard is a baseline ECG (or within the past 3 months) and then follow up ECGs depending on dosage increases, risk factors, and other subsequent medications that can prolong the QTc.
      Risk factors for QTc prolongation are as follows: hypokalemia, hypomagnesemia, age, female sex, advanced heart disease, congenital and acquired long-QT syndromes, family history of sudden death, anorexia, bradycardia

      (2) Please give a perspective of the magnitude of these changes compared to methadone: the pharmacy times article referenced at the end of the blog also features of comparison of buprenorphine QTc prolongation to other common culprits of QTc prolonging drugs. The following Medscape article features a great literature review/comparison of methadone and QTc prolongation but again multiple factors should be considered and the extent of prolongation will be patient specific. The range in these studies depending on dose was 21-77 msec change in QTc: http://www.medscape.com/viewarticle/707342_3

      (3) Please let me know which Cyt p450 metabolism pathways most likely contributes to the QTc prolongation: any drug that would inhibit the metabolism of buprenorphine in this case would increase the likelihood of QTc prolongation. For buprenorphine it would be primarily 3A4 and for methadone it would be CYP3A4, CYP2D6, and to a lesser extent, CYP2B6, CYP1A2, CYP2C19, and CYP2C9.

      1. As an addition to Dr. Pratt Cleary’s comments, the mechanism for QT prolongation for both methadone and buprenorphine is attributed to their ability to block potassium channels encoded by the human ether-a-go-go-related gene (HERG) that are responsible for cardiac repolarization. The following article examined various opioids in their ability to inhibit these potassium channels and may be of benefit in explaining the differences in QT prolongation magnitude: http://jpet.aspetjournals.org/content/303/2/688.full.pdf+html. If the link doesn’t work, here’s the reference:
        Katchman AN, et al. Influence of opioid agonists on cardiac human ether-a-go-go-related gene K(þ) currents. J Pharmacol Exp Ther. 2002;303:688–694.

  122. Jeff, this works about the same as Actiq? Only, no rubbing of the sucker on the inside of the jaw, “mucosa”. I have had Arachnoiditis/adhesive type for the last 15 years. NOW, two weeks ago they found cancer on the S-1 nerve root. So, now, another beast has entered my life. Long haul. Since workers comp has taken me off everything, “ins cure”. They said for me to “meditate/ accupuncture”, this was before the cancer. They may put me back on, the doc has written some letters. Would this Buprenorphine work like the Actiq? Thanks, Herb Neeland

  123. Unfortunately, even when we try to use buprenorphine for pain, we frequently encounter problems with “refusal to fill” because of misperceptions around the need for the Class X DEA Waiver and the differences in regulations surrounding use in pain and the use in opiate addiction treatment. Perhaps a good followup piece on this blog for your always on-point students and residents?

  124. I tried it and it made me so SICK. So now I take suboxone for my fibromyaliga and its been a miracle for me, it gave me my life back.
    I was on so many Drugs and all they did was make me worse.
    I was on 80mg. OxyContin 3 times a day + all kinds of other drugs and I’m so glad I found suboxone I’m up and doing things that I used to do.
    I just wish more people new about it. It’s been such a miracle.
    And the best thing about it is that’s all I have to take.
    I’ve been on it for about 5 years

    1. Jana, If one buprenorphine product made you sick and the other did not, it makes me wonder if you were on a pure opioid prior to initiating whatever buprenorphine product you previously had. If that was the case, it wouldn’t be from the buprenorphine itself, but rather it would be from opioid withdrawal. The same would/shoul happen with a therapeutic dose of Suboxone.

      1. No i had been off all opioids for 6 to 8 months.
        I got off all the other pain meds on my on slowly and did fine.I never went through any withdrawals. I’ve never had a problem with drugs at all.

        1. maybe some people just can’t take it. My Dr.s follow me very closely. I don’t know why I couldn’t take it. But I’ve been fine on suboxone. Maybe just the buprenorphine was to strong by itself.

          1. Buprenorphine is the main component of Suboxone. The only difference between Suboxone and buprenorphine is that Suboxone also contains naloxone. To be honest, if someone were to state that they couldn’t take buprenorphine- only Suboxone- well.. it simply doesn’t make any pharmacological sense.

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