Buprenorphine, so misunderstood

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:

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.


686 thoughts on “Buprenorphine, so misunderstood

  1. I am a sixty year old retired instructor living alone in Ohio. Over my lifetime I have sustained 38 broken bones due to sports and a severe accident in 1990 that nearly caused me to loose both of my legs. It took three years before I could walk without the use of crutches or a cane. I have also had severe injuries to my spine due to the same accident. Needless to say, I have been left in chronic pain ever since. During that passed forty years I have been on every known pain medication that has been available from Oyicontin to Opana and everything in between, all of which caused more problems than good. I am reaching out at this time because after researching your new product. It seems like something that could really help the quality of my life. I have recently lost my son and daughter-in -law in an accident that left us with two granddaughters to care for and the pain that I live in gets in the way of living the way I feel I should be. This country is in such a horrific mess ever since Purdue Pharma put Oxycontin on the market, people like myself can’t get the help that we so desperately need.

  2. I tried it, and it was so sick. Then I started taking suboxone to treat my fibromyalgia. it’s been a blessing for me. It gave me the quality of my life back.I had tried a variety of Drugs and only made me feel worse.
    I was taking 80mg. OxyContin three times a day and all sorts of other prescription drugs. I’m so happy to discover suboxone. I’m now doing the things I did not do.
    I wish that more people were aware of it. It’s been an absolute miracle.
    The best part about this is that it’s all I need to take.
    I’ve been using it for about 3.5 years.

    1. I was on suboxone for many many years. When I first started taking it, it helped with withdrawel, and Gave me a long term buzz that helped me become an emotionless work zombie. I loved the feeling, because I wasn’t high, but I wasn’t sick.. I had control to warm my day… But as time went by, I realized it was a crutch, and I git tired of being an antisocial zombie, often missing family events and not wanting to socialize on any level. I began developing dry eyes, and many allergies to common things as my body began to reject it. By the end of my treatment, I realized it was time to get off. Unfortunately, the violent Neverending withdrawel set in and I had to take pain medication through the detox. The suboxone detox for me went well into 2 whole months. Never could I imagine that it would take that long to feel normal. Even after this detox, I couldn’t drive myself to do much of anything like normal at work. Therefore, I began to dabble in opiods once again… Sadly, I became a worse pill addict then I was before, and worst of all, Suboxone no longer works for me. In fact, it makes me sick, and the bupe does not supercede the withdrawel from the latter. Long story short, suboxone is a crutch, but people need to realize that it is not the problem solver nor is it something you should plan on bieng on for long. The withdrawel on suboxone is far worse and far far longer than any other opiod. Other opiods have about a 5 day detox, and if your not working you can take benzo and ambien to sleep your way through it. Suboxone is 80 times as potent as morphine, and it’s half life is 4 times as that of oxycodone time release tablets. Your setting your self up for a hard road if you plan on staying on suboxone for anything longer than a couple weeks. As far as bucca…This is an extremely watered down version of subutex. To a person who never had experienced bupenorphine, they will most likely appreciate its effects. However, you still need to inform yourself of what you are taking, and the detox is far from fun. In conclusion, make sure you really pay attention to what you are putting in your body, and be mentally prepared for what can happen in the long hall. In my case, I was addicted to Suboxone as my drug of choice for well over 10 years. It was a very “blah” lifestyle, but I learned a trade and now I can afford a high middle class lifestyle for me and my family. It helped me through the hard uphill battle in life, but at the price of never truly recovering from my addiction. Thank you for reading.

    2. John,

      Congratulations! I have Fibromyalgia too and am in a ton of pain. May I ask what dose you started on the Suboxone?

  3. I have a family member who has severe chronic pain from RA that they left untreated for many years because they have always been against taking pain meds until the flare ups got unbearable. They tried to get prescribed pain medication but the doctor would only offer them a high dose of Tylenol and pushed them out the door. Even when one of their joints would be double or triple it’s normal size. Which led them to getting 30mg “oxy” from someone they trusted. Finally got to see a PM and got their urine tested, turned out to have adderall and fentanyl in it mixed in as well. So here’s my question;
    The PM doctor prescribed them belbuca, which they have been taking. At first (450mcg) they felt like it was working well and not making them go into withdrawal. After a few days the doctor told them to up to 600mcg. After they tried that it made them feel withdrawlly and they described it as feeling “stoned”. So they reduced their dose to 150mcg and say they really do not like the way it makes them feel. Tight chest, night sweats, cold etc. they tapered down the 30mg “oxy” to about 10mg. They have now been taking the belbuca for over a week at 150mcg once a day due to having to run their own business and the belbuca makes them feel too bad to function properly throughout the day. They have also developed really bad anxiety. Why is this? Is it because the belbuca needs to be taken 2x daily? What are the reasons for the tight chest? (Allergic, or side affect?) what effects could the adderall and fentanyl have on the belbuca?
    They are also taking 5mg prednisone daily, along with 2mg tizanidine as needed.

    1. Olivia,
      There are several issues here. First, it us NEVER okay to take oxycodone or any other prescription medication that wasn’t prescribed, and possession of oxycodone without a prescription is a felony. Now that we’re past that, using Belbuca at that dose and in close proximately to oxycodone will cause withdrawal. Secondly, the dose was dropped too rapidly, which also could have caused withdrawal as described. It would be best to start at a low dose and titrate up, rather than start high and titare down.

      1. Hi Jeffrey, I have been looking everywhere to try and figure out the conversion system for buprenorphinre products. For example the patch (10mcg/hr verses subtext 8mg tabs and the 300 mcg sublingual films or strip.. can you give me a few examples or tell me where to find a table. Anything really.
        Thank you, Lporter

      2. I have been on bupornorphrine for a while now. I started with the strips at 150mcg for pain managemnt after years of prn percocet that I just dis not want to keep taking daily, and I had an overwhelming sense of anxiety and adrenaline. So much so I was calling my doctor at 2am telling him I felt dangerous to myself on the new med. They switches me to the patch form. I have a bad blistering reaction and have to put flonase on first and then the patch. Still each time it leave a welt on my skin and is super itchy. By 2 days in of the 7 days i always have to remove the patch and clean my skin or it will start to blister. I started at 10mcg and am up to 20mcg. I still feel like crap. Every week by day 5 I experience extreme leg pain and get sick, like a hangover. Is this me withdrawing every week? Is haveing to remove it by day 2 to clean area making the patch useless the rest of the week and by day 5 i start feeling withdrawl? I have asked the doc about this and he says no, but it is what I feel. I mentally cannot handle the strips again and am stuck with the patch. I even asked to just go back to the percocet and deal with only getting half relief than experiencing this every week. Doc said no to that too. That i would need a referral to new pain management if the patch wasn’t helping. I have been with his office for 20 years now and I do not want a new referral, I just so not want these side effects. It is like he doesn’t think it is possible to feel this way on the patch and I get the impression he doesn’t believe me that this miracle drug(in his eyes) isn’t working and is actually making things worse for me. Also in just this year I have had 5 cavities. I have gone years without any and now all a sudden, i have 5???

    2. I have stage 4 RA and you do not mention this patient on any RA drugs?? Immune suppressants they will NEVER feel better with out RA treatments period. It will kill them. I’ve had it 30 years and just going off of treatment 2 years for surgeries and illness I’m stage 4 only 1 in 100.000 get stage 4 ( meaning there’s no longer remission and it’s getting in my organs) I’ve lost so many all ready including my large intestines 🙁
      Please have them seek the right help.ASAP

  4. Is there any role for this type of therapy for Chronic daily migraine patients/sufferers who have continuous migraines, do not respond to any of the triptans, Gpants, any of the preventatives including Botox, including the latest monoclonal antibodies, including anti-convulsants, anti-depressants, anti-psychotics, blood pressure medications such as beta blockers, and have pain levels of seven or eight, 24 hours a day, seven days a week? The conventional wisdom among neurologists is that this type of therapy does not work for migraines and there is no use case for it, even in the most challenging cases, even in the most intractable and refractory cases. What is your opinion about the use of this type of therapy with this type of patient As a last resort where the patient’s quality of life is essentially zero?

    1. Have you ever tried having nerve abortions in your neck for migraines. I had horrendous migraines that caused me too much pain to function. Turns out I have occipital neuralgia and this treatment has been a lifesaver.

    2. You may be dealing with serotonin syndrome depending on what you take for medications it can cause the absolute worst migraines and pain in general. It’s one of the most misdiagnosed and underdiagnosed medical conditions all over the world! It can mimic many things like chronic migraines , fibromyalgia, neck and spinal pain , to pure pain from hell like every nerve has gone insane so your body feels like it’s been sunburnt super bad and then take an imaginary person slapping it over and over again to where you can’t touch your skin,
      It can mess your body up so bad and you won’t even know there’s anything wrong but people who know you or speak to would be able to tell ( yes being super happy can actually kill u!) Metabolic acidosis serotonin syndrome.
      I spent my 20s in pure migraine hell and with neck pain some times my back. I always felt horrible nothing the Drs did helped. While a dose of pain medication would help it also helped slowly make it progress till eventually my body just couldn’t handle it ‍♀️ either my heat gave out or I would land in respatory distress also known as cns depression I’ve landed in cardiac ICU regular ICU been in two comas on life support it destroyed my life. I eventually got off all the crap and I spent about almost two years pain free until I damaged my spine and then a year later was assaulted and the blows to my spine where the last it could take I finally was taken seriously at just barely 30 I wasnt given good news and the only safe way there was for me to get pain relief was opiate pain medications because I’m unable to take the anticonvulsants most anti-inflammatories antidepressants, can’t do Lyrica, gabpentinton, or neurontin, I’m not even a candidate for injections in my my spine not that I would go through that again knowing what I know now they actually cause more damage not FDA approved or approved by manufacturer for injecting in the spine in any area including the neck! There’s also a black box warning of neurological problems they can cause. I have had MRSA staph and am a carrier as well as multiple autoimmune disorders so it’s not recommended I had to get a recording of the FDA saying that because that’s pain Drs cash cow are those injections and they screw up you could live in more pain for ever. Buprinephrine causes serotonin syndrome and it can cause a ton of horrible side effects it can cause spinal pain and bone pain messes with your thyroid so if you have a thyroid issue you will have issues alot of people also deal with neurological issues so your brain feels like it’s being electrocuted my anxiety was so bad I couldn’t ride in a car I can’t handle noise and my body goes completely nuts well only positive of this was I got my Valium back which slowed the serotonin syndrome but any Dr with a brain knows that’s a temporary fix and it stopped the brain zaps and made it so I could tolerate noise and being around moving people and ride in the car again and it does help my pain one the days it’s not causing exscutiating pain that’s what I got when my Dr bailed saying I did nothing wrong we will no longer be treating patients with pain medications the pain drove me to attempt suicide and I broke down and went on buprinephrine cause they had been trying to get me to try it for years and besides having it after a C-section with Dilaudid and toradol so I knew it was used for pain I never thought I would be back in hell again! Now I understand why Drs stopped using it as the preferred drug for chronic pain in the 80’s the Suboxone and this push patients on Suboxone Subutex belbucca basically any brand of buprinephrine is their way to make up for a false drug Crisis that’s left millions with no way to treat pain thousands of pain patients that have taken their own lives or their bodies giving out due to the pain. We have an illegal fentanyl and heroin issue and studies have shown 1% of the population are addicted to pain meds because they misused them.
      If you wanna have insane migraines then go get put on some form of buprinephrine sadly I also learned that it’s horrible to come off of. Sadly I’m still stuck on it no Dr will even think about treating my pain with medications that made me have a quality of life I’m stuck with no quality bof life even if my pain is controlled because I completely reject this medication did I mention the black outs and how it makes me super depressed at times yah my Drs have no plans to actually help me and ones that suffer are my kids my family and then myself‍♀️
      So hope that may give you some answers ‍♀️

    3. Personally I hadn’t had a migraine in years and had 3 the first week I took Belbuca 150 mg 2x a day. I was anxious, depressed. Crying, (and I am not a cryer) and couldn’t sleep. I was miserable.

      But… I know everyone had their own experiences with different medications. I had been taking hydrocodone 3-4 times a day for years and years and never had a problem with addiction or taking more than I should have etc. I hate that it’s considered “the bad stuff” when, for me- it was working. “If it ain’t broke don’t fix it.”

  5. How interesting that you talk about how QT prolongation is discussed a lot. My son has become addicted to opioids. I will find a reputable suboxone treatment center locally for him.

  6. Hello, I am 46 and have sticklers syndrome type I which is causing me moderate to severe pain daily, due to progessive osteoarthritis affecting most joints, hip impingement, and other musculoskeletal problems. I started using butrans 15 months ago and after several months of skin peeling at the patch site switched to belbuca. Before that, I only had tramadol, limited to 150 mg total a day.
    The tramadol did not help much at all and combined with my SSRI and migraine medications caused undiagnosed serotonin syndrome, severe anxiety and panic attacks, sweats, slightly prolonged QTc interval. (I have not been able to use nsaids at all for five+ yrs due to ulcers and gastric irritation.). I did slowly taper off a very low dose benzo which I had used to help manage severe anxiety and panic attacks; and reduced a very high dose of prozac to a moderate dose. But, after I got off tramadol (and onto butrans) the horrible anxiety was very reduced and panic attacks are mostly gone (not daily). (I did trial snri’s and neuroleptics and had bad side effects and little relief.)
    I am finding that Belbuca is very helpful in managing most of my pain but if I overwork I do have bad breakthrough pain. I am trying to get in better shape as I think that will ameliorate the problem by keeping my joints more stable and reducing weight on joints. I gained 30 lbs since I have gone gluten free but also had to stop hiking and walking and so many life activities. Belbuca has made my life so much better by reducing my pain after I’ve requested pain relief for so many years. I am less depressed and starting to resume activities that I dropped because of pain and exhaustion. I have much less pain related nausea and dumped my ondansetron prescription, too.
    I have a couple of questions: i just figured out that some of my sleep problems and night sweats/ chills and restlessness only happen when I forget my nighttime dose of butrans (currently 750 but returning to 600 in April). Is that reasonable/ sensible or is that my imagination? Of course, the pain makes it hard to sleep if I forget…
    Also, do you know if butrans and belbuca are often used to treat patients with connective tissue disorders like sticklers syndrome (eds, marshals, marfans)? I can’t find a standard of care for pain management of stickler’s syndrome, and stopped going to the university pain clinic because the dr there was so negative and judgemental. since I have bone on bone arthritis in one knee, arthritis, dislocations, deformities in multiple joints, multiple synovial and bakers cyst, tendonitis, etc. it seems reasonable to me that I would be having a lot of pain. I am 46 yrs old and predicted to be needing joint replacements soon. Why is it so very hard to get my pain addressed? admitting to pain should not be considered a character flaw, and wanting relief not an indication that a person is a whiner/ drug seeker.

    1. Hgerbyshak,

      Missing one dose of Belbuca at night should not generally cause withdrawal symptoms because the half-life is about 26 hours. BUT, it is certainly possible. Yes, Belbuca can be used for any chronic pain syndrome such as Sticker, although as you mentioned, there is no specific standard of care on how to treat Sticker-associated pain, other than starting with anti-inflammatories. I don’t know the specifics of your gastro-intestinal problems, but you may be a candidate for a COX-2 selective NSAID starting with etodolac. Other COX-2 selective options are celecoxib of meloxicam. Any of these would require that your doctor make a full risk assessment and a prescription.

    2. God bless you and you are affirmed! Pain is not a character flaw not is it a reason for others to judge us! Medication of these sorts were meant for people with horrific bone, nerve and soft tissue pain….people do not understand…..it’s sad because it makes us worse and more isolated. Hang in!

      1. I have been generated this disease which is been progressing for the last 13 years I know how it L2 L3 L4 L5 S one and a new pain that is going into my kneecap that’s from my back I went to the neurosurgeon he wanted to do a fusion which they wanted to do 10 years ago and I said no because after two failed surgeries not field surgeries but scar tissue is my dick problem. Anyway after looking at this MRI the neurosurgeon knows I have no pain medicine at all and I don’t have an appointment for 20 more days tells me to hang in there I’m halfway there. I wanted to hit him. I been taking Burpernorphine 8 mg sublingual but one and a half which my doctor is prescribing was not enough the pain is too intense and I know it takes six months for these just heal and I’m in my third month. If my anesthesiologist had to walk around with the kind of pain I have they would be walking around I need a be a little bit more understanding this pain has robbed me of my life.can’t sit for more than 10 minutes can’t even walk a block because of pain in Sciatica waist and kneecap. Anyway is there anyway that I can be prescribed a higher dose they keep on talking about micrograms but when you read the strip or the pill and says 8 mg. I haven’t had any real pain medication like oxycodone for over six years. Burpernorphine doesn’t make you sweat it doesn’t last for more than 12 hours it’s a perfect medicine for me if they just made a higher dose

        1. Christine, Buprenorphine comes with snd with naloxone and can be doses many different ways, so there are options. Those options also depend on whether or not it is also being used for an opioid use disorder, fir pain, or for both. 8000mg = 8mg

        2. I would love to punch a lot of doctors in their lying mouths. What satisfaction. And by the way they are not in pain. Are they?

    3. I truly love how you said your last sentence. It was so honest and so simply put. So very very many of us pain people feel the exact same. With no help ever in sight. I hope you soon find relief so that you can live again. You are such a young woman to be suffering as you are. I find it interesting that the doctor did not answer your question. I would have liked to have heard his honest opinion on this. Be well

      1. Rae, I did answer her question some time ago. It said…


        Missing one dose of Belbuca at night should not generally cause withdrawal symptoms because the half-life is about 26 hours. BUT, it is certainly possible. Yes, Belbuca can be used for any chronic pain syndrome such as Sticker, although as you mentioned, there is no specific standard of care on how to treat Sticker-associated pain, other than starting with anti-inflammatories. I don’t know the specifics of your gastro-intestinal problems, but you may be a candidate for a COX-2 selective NSAID starting with etodolac. Other COX-2 selective options are celecoxib of meloxicam. Any of these would require that your doctor make a full risk assessment and a prescription.”

  7. Hello. I have Stage 4 Endometriosis with severe chronic pelvic pain which radiates into my left flank, lower back, through my hips, buttocks and down my legs. I have had this incurable, often debilitating disease for exactly 30 years this month. For the better part of the past 10 years, I have been under the care of pain management doctors (I say doctors, plural, as I have relocated/moved 3 times, living in 3 different states in the past decade). I have a relatively high tolerance to opioid medications and depending on the medication and whether or not I am receiving a dose adequate to manage my pain, I do well with opioids, and again, if the dosage is adequate, it makes all the difference, with regard to my quality of life, ability to get out of bed, tend to chores, and lead a healthy, moderately sociable life.

    My doctors in both California and in Texas were great about prescribing me what works best for me and they were not afraid to prescribe me the dose and quantity that well managed my chronic pain. For example, my “sweet spot” for pain relief is 20mgs of Oxycodone IR, 6 pills per day. It was even better when I was still able to receive Soma to take as needed during my worst pain flare days/weeks, but due to the misuse and abuse of Soma with opioids and/or benzodiazepines, I’ve had to go without the only muscle relaxer medication that has ever helped my pain. Considering my pain quite literally feels like that of labor pains and contractions during childbirth, only about 15x worse, as well as all of the “pulling” and twisting pain that’s associated with Endometriosis, scar tissue, adhesions and Adenomyosis- all of which cause me such excruciating pain. I require opioid medication to not suffer.

    Finally, my question and my concerns. As the DEA or the CDC has released those guidelines in recent years, placing a “cap” or a suggested daily dosage of no more than the equivalent of 90mgs Morphine, I’ve only been receiving a total of 60mgs of Oxycodone IR each day. For years, as I mentioned above, I’d been taking twice that, at 120mgs Oxycodone IR each day. Needless to say, because of this ridiculous one size fits all ruling by the government, my pain hasn’t been well managed these past 3 years. My quality of life has lessoned dramatically, and I am no longer able to be relied upon to even attend family functions, make plans with friends, plan for anything really. This includes my wedding. For the first time in my life, I am engaged to be married. I am 42 and I do not have children. My pain isn’t being managed well enough for me to even set a date, let alone feel excited about the big day, for it’s more likely than not that I’ll be in so much pain that I’ll not be able to get out of bed for longer than 15 minutes, and I’ll certainly not be able to leave behind my holy grail heating pad for any longer, either.

    So, just last month, after unceremoniously and without any tapering down or a referral or any resources whatsoever, my PM doctor of 3 years (he’s the ONLY PM doctor in this area) – he dismissed me from his care. Why? Because I ran out of my medication early, as I’d been in nonstop pain, and taking 20mgs of Oxycodone every 6 hours was not helping me. So, yes, I absolutely took 20mg every 4 hours, along with 800mg of Ibuprofen every 8 hours. I never once asked for an early refill. I never once missed an appointment. I never once failed to comply with the random urine screens and all of the other ridiculous hoops that we chronic pain patients are forced to endure. I did the best I could with what I was given. It was his prerogative to dismiss me from his care, but I feel that, considering my health conditions, chronic pain that has actually grown even worse since I had my diagnostic lap surgery performed by a less than skilled gyno doctor in 2015, and I’ve been taking and dependent (not addicted- dependent) on opioid medication to just live as normal and as productive a life as I can, to essentially “fire” me as his patient without even prescribing me as little as days or a couple of weeks worth of medication, and without giving me any idea of where I could turn or what I could do- in my opinion, I feel that he not only let me down. I feel that he betrayed the very oath he took when he became a doctor, as what he did most definitely harmed me.

    Thankfully, I am a resilient, strong woman and I am a fighter. I refuse to give up, in spite of so often wanting to. I searched and found a pain management clinic about an hour from my home in another state (I currently live in Western Kentucky. My new PM doctor is located in Tennessee). Which finally brings me to Belbuca. My new doctor will not prescribe me the 20mg Oxycodone IR I have taken for nearly 6 years. She will only give me 15mg Oxycodone IR, 4 a day. It’s just not enough. It isn’t. So, she mentioned the whole 90mg Morphine equivalent “law” (but is it, really? is it a law or is it a firm suggestion or preferred ideal? My understanding is that it is NOT illegal to prescribe more than 90mgs daily Morphine equivalent, but the doctors act as though their hands are tied, whilst a patient like me is expected to just suck it up and be grateful that I get anything at all. I don’t think that is how it should be. It’s not right. It’s certainly not in the best interest of me or anyone else who suffers with chronic, incurable pain that is debilitating.

    But, I digress. So, what she prescribed last week was my drastically inadequate dosage and quantity of Oxycodone and she suggested I try Belbuca. I am familiar with Buprenorphine, as I give a cream compound of it to my elderly, arthritic cat. I am well read about pharmaceuticals (particularly the ones which I have taken, those I’ve tried which either failed me or benefited me, etc). My understanding of Belbuca is this: It has a ceiling effect. It will block my opioid receptors, rendering the Oxycodone completely useless. So, finally, (and I do apologize for this thesis of a comment, but I am a writer. Moreover, though, I am confused and conflicted. While I am being ridiculously undermedicated with the amount an dose of Oxycodone she is prescribing, it still is better than no oxycodone. I cannot wrap my mind around how she would think that me taking Belbuca twice a day would behoove me in any way. I need to know if it is going to render the oxycodone useless or even just far less therapeutic. She said that Belbuca is excluded from that oh so delightful DEA 90mg Morphine equivalent “rule,” so she could prescribe this buprenorphine for around the clock pain (when what I know would be far more appropriate and effective would be Oxycodone ER, with my 4 15mg Oxycodone IR to take for “breakthrough pain.” I do not want to start taking Belbuca if it is going to render useless my Oxycodone. I am a person living on disability because of my pain, so I don’t have the money or the ability to play around with medications that could potentially cause what little pain medication I have that has proven to work well for my pain…cause it to be essentially a sugar pill. That is upsetting to me. Also, to add insult to injury, as Belbuca isn’t yet available in a generic form, and for some reason, my Medicare insurance refuses to cover the cost of this new medication. Even with the discounts that my wonderful pharmacist was able to apply, I will still be paying nearly $200 out of my pocket each month. I’m set to go pick up the Belbuca tomorrow (2/17/21). If any of the medical professionals/doctors who run this site reads this and has any advice, additional knowledge, wisdom, etc, please please PLEASE respond to my message.

    Is it worth it to start and try the Belbuca?
    Is it, more likely than not, going to render my Oxycodone useless, preventing it from reaching the receptors in my brain which aid in pain relief (or rather, the perception of ones pain)?
    Does Belbuca, if started without any regular opiod medication in my system (as to not incite and trigger withdrawal) going to have potential to work in harmony, possibly potentiating the effects of my Oxycodone (my gut tells me this is wishful thinking and that it will likely do the antithesis of potentiate the Oxycodone.

    I could really use some help, guidance, additional wisdom, and brutal honesty. Lay it on me, doctor(s). I don’t want to make my circumstances worse, and I certainly don’t want to go spend money I don’t really have to do just that.

    For whomever reads this and replies, I thank you in advance. I appreciate your time and any valuable, vital information you might have to offer.

    Best Regards,

    1. Casi,
      Thank you for your note. Perhaps I missed something in here, but if your pain is 100% related to endometriosis, I would expect this pain to be problematic for 4-7 days each month, not daily. And if that’s the case, I would expect that prescribing opioids would be less of an issue if you were compliant. That aside, to answer your questions…
      1. 90mg Morphine equivalent is not law. There is no law in any state that precludes certain doses, but there are cut-offs that require more justification on the part of the doctor in some states.
      2. Belbuca could be helpful, but it is not meant for intermittent pain for one week each month – that could be tricky.
      3. At higher does of Belbuca, 900mcg twice daily, the oxycodone will be less effective but not totally blocked. And at the lowest does, less oxycodone activity will be blocked. This is because the higher the dose of Belbuca, the less percentage opiate receptors are available to be occupied by oxycodone.
      4. Another choice that perhaps your doctor would consider instead of Belbuca, is tapentadol (brand name, Nucynta). This could offer you very good pain control, as it has a dual mechanism, and if your doctor can convince your insurance to pay for it, it could be life-changing. It is an atypical opioid that also does not have an “exact equivalent” to morphine.
      The following articles may help.
      The MEDD myth: the impact of pseudoscience on pain research and prescribing-guideline development
      Tapentadol: A Real-World Look at Misuse, Abuse, and Diversion

      1. Hi my name is Brian I’m going threw the same thing with my pm doctor and do not take balbuca with any opiates it will put you in with draw and the belbuca made me very sick my wife got pur friends to load me in our van she took me to my doctor’s office to show him and his staff how bad I was and he said they wouldn’t have beleave if they didn’t see me in that condition he no longer perscribe belbuca that drug is worse than 200mcg of fentanyl lol please dont take belbuca. There is no help for pain patients like us stay in touch. We need to get a group of us together and take it to our state llol

      2. Wow I’m sorry but anyone who knows anything about endo, especially having stage 4 knows it is absolutely not just during menstruation. The very way she described it, that is what I go through as well. My doctor said it looks like someone got a bottle of glue and squirted it all over all of my organs. My heart included! The very fact that I’ve had surgical procedures increases my risk of it even traveling to my brain.

        This is the very reason endo is not taken seriously because the stigma that it just goes hand in hand with menstrual cycles. No but my cycle lasts about 10 days. And about 3 out of 4 weeks it literally feels like mild labor pains.

        1. Jen, I understand that Endo pain can and often goes beyond the menstrual period friending on stage snd involvement of the disease. For that reason I plan to engage a women’s health expert to write a blog on this topic and start a response chain.

        2. I had Endo, and my sister did too; she ended up losing part of her internal organs due to the severity of her disease. I had three weeks of heavy period flow, a few light days, then the cycle would start again. It began as soon as I started my period at age 15. I had it in high school (undiagnosed) and my principal told me that every woman has periods and to suck it up. I was diagnosed while serving in the Coast Guard. it was extremely painful and exhausting due to the loss of blood. A radical Hysterectomy (due to docs repairing abdominal trauma from being stabbed and beaten by my ex-husband, and them discovering Leiomyosarcoma) solved the issue of Endo pain. Every single patient is different.

          There are many PM treatments, but when someone goes into a PM office and speaks to the staff as if they are ordering from a clown’s mouth at a drive-thru, they will be labeled as a drug seeker and have problems getting help and meds. Add to that, when someone takes more than prescribed, that is another red flag. There are times I have to take more medication than prescribed, but I call my PM doc, she documents my file, and she understands. A lot of it breaks down to trust. Change to a different PM office but understand they are not pill dispensaries. PM docs can lose their license or worse. My cousin was in a bad car accident and started seeing a PM doc. He died about two years later from a drug overdose while taking the prescribed amount of his prescribed drugs. His PM doc is now in prison.

          I live in pain daily and understand PM is to alleviate pain, not remove it. I understand my PM is a person and doing the best she can to help me. There are nights I cannot sleep, there are days I cannot get my work done, and there are many, many days that I cannot play with my grandchildren. But, I understand each of us is on a journey and life is hard. We must learn to walk through this world with dignity, grace, and do the very best we can with the hand we are dealt.

          I pray for peace and pain management for each of you!

      3. I have been taking 30-40mg of oxycodone for years. My doctor wanted me to try Belbuca. I told her I would try it. I have got myself down to 5mg of oxycodone twice a day in preparation for the Belbuca and I have been suffering. She prescribed 450mg twice daily and said I can take my oxycodone with it. I am so nervous to take it. What are your thoughts?

        1. Be very careful taking Belbuca, my PM doctor started me on it 3 years ago for RA pain and Herniated disc’s. Within that time I began having horrible tooth infections, I had only ever had 1 cavity in my life. Now I have had to have several extractions and major dental work on my top teeth. The last infection made my face swell until my eye wouldn’t open. No one warned me about this and know the FDA is saying this as well. In my opinion I would rather live in the pain I had it only has caused more pain. I am being switched to Tramadol Er to see if that will help. Everyone taking Belbuca should be warned about this!!

      4. Hello. At this time. I am currently far too exhausted to adequately reply. I just need to specify that I am in pain ALL the time because of my Endometriosis. Not just during my period. I am 43, and since my first period at the tender age of 12, I have suffered pelvic and lower back pain that is identical to labor pains during childbirth, but at least 10 TIMES more excruciating. From age 12 to 18, I missed countless days of school and I also had to cut back on my dancing and other activities for which I have a great talent and passion. From age 18 until my mid 20s, I was on birth control and I tolerated it so well. Those 6 years, I had a dramatic reprieve from my miserable pain. Then, after experiencing a brief pregnancy, a number of complications arose (it triggered and began what has now left me a disabled person unable to work since 2007; that brief pregnancy triggered 2 additional serious, incurable autoimmune diseases and mental illness which grew so bad that it left me even more debilitated than my near-constant physical pain).

        I tried, for years, and many different types & brands of birth control pills- after that brief pregnancy, and a subsequent, equally as brief pregnancy, I have not been able to tolerate ANY hormonal contraceptives. Not only did “the pill” stop helping with my awful pain, it actually, drastically worsened both the Endometriosis pain AND my mental health.

        I am so frustrated by the very real fact that I do, in fact, know more about my diseases (Endometriosis and Hashimoto’s) than ANY medical professional, doctor, pharmacist, lay person, etc. It is both infuriating AND so disheartening to have to fight these things, advocate for myself, navigate all of the bullbutter, AND inform everyone including the now countless doctors, nurses, pharmacists, and other medical professionals I’ve seen in FOUR separate states across the USA.

        I will try to return here when I am rested and not feeling as crappy, as it is clear that I am going to have to educate and inform you and anyone else who may read my comments. I am not being rude. Honest to goodness. I am just so tired and frustrated with the lack of understanding and willful ignorance that permeates our world, with regard to Endometriosis and women’s bodies, women’s issues, women’s diseases, etc.

        So many times, I have had to live in this body that I love in spite of the sorrow and suffering it causes. But I can and I will forge ahead. I will not give up. Still, and I feel quite comfortable speaking for the overwhelming majority of the *1 in 10* women across the world who suffer with this excruciating disease that acts a lot like a cancer, only it rarely actually kills us. This sisterhood of sorts- we are so fed up with having to live and fight this. That’s difficult, painful, and exhausting enough. But the fact that we also have to explain in detail and correct misinformation to everyone (including the aforementioned medical professionals who literally have NO EXCUSE for being and staying willfully ignorant and complacent regarding this rather common disease) who doesn’t have this awful illness?

        I firmly believe that if Endometriosis were a “men’s disease,” not only would society be better (well) informed…I suspect there would be a cure. And I also doubt that men would be patronized and gaslit by countless doctors who just DO NOT BELIEVE US when we say we are hurting so badly that it is very often completely debilitating and again, like going through the most horrendous labor pains, not for hours or even just days- but rather, for WEEKS. MONTHS. YEARS, DECADES.

        I just wrote far more than I intended, but if my words and my self advocating can help another woman or the future generations of ladies who will suffer this despicable disease, perhaps my own lifetime of suffering and lost opportunities will not be completely in vain.

        I implore you and everyone who may read this: Please be proactive and remember, Google is our friend. Take a few hours or days to read, listen to the testimony of other Endo Warriors, and with the knowledge you glean, you’ll never again casually presume that it’s just a “time of the month period thing.” It’s NOT at all just that. Not for most of us. We are good at looking well, smiling, going above and beyond to make others feel comfortable, and looking lovely. So, you won’t often SEE our misery. It’s invisible to the naked eye. We have had no choice but to evolve into badass warrior women who navigate this life with a smile and pleasantries, even as we feel like we are being ripped open and gutted most of the time.

        1. Casi, Thank you for this thoughtful and candor on your post! I will follow-up with an email, but I would like for you to write a guest blog with for paindr.com basically including much of what you said here and expanding if you wish. Then, if you’re up to it, I will inquire with Practical Pain Management to see if they are interested in a publication or a Podcast interview.

        2. I’m merely asking, as I’m uncertain as to whether this would end your suffering, but I noted that you said you were 43 and had been suffering with endometriosis since early teen years. I’m thinking, and I could be wrong, but at 43 you’re most likely not planning on more children, would a hysterectomy at this point put an end to the suffering from endometriosis and all the navigating the spectrum of finding and receiving adequate pain management? Again, simply asking as it’s not something I’ve ever suffered from however my daughter did and that was one of their first recommendations despite her young age.

        3. Dear Casi,
          if you have not birthed a child how can you compare your pain to labor pains? 10 to 15 times worse sounds a little exaggerated. ANYHOW…………..
          I LOVED my pain meds, (still occasionally miss them.) so It took time for me to except that I needed to try something different bc the opiate pain meds were no longer working very well anymore and I was getting tired of running out of my meds and going through withdrawal symptoms month after month. Even the extra 30 tamadol I was given on top of the 90 perocet each month was still not enough to end my pain. ( END being the key word here)
          With no other choice and with severe reluctantance I choose to go different route. I had a friend who went from a 160 Norco a month to a 20mcg/ hr patch of buprenorphine and to her it working. So I had a talk with my PM Dr and we decided on a 10mcg/hr for 24 x7 patch for me. A fairly low dose, considering that I used up ninty 10/325 over two weeks plus 30 tramadol. In hind sight I should have been more honest about how often I would run out he could have started me on a higher dose, but it actually worked out bc now I can get a slight increase.
          It has taken a few months but I am slowly starting to understand that my reluctance to trying something new was created from my dependency (addiction) to the opioid. There is always going to be a need for a higher and higher dose, due to an increase in tolerance. (So when do we stop, when we overdose and die?) If you had asked me awhile back if I thought I would need a repeatedly higher dose of meds I would have said NO!!! Just give me the dosage I want now and I will be content with it. I said that before the extra tramadol script too.
          Anyways, I have been on buprenorphine going on 6 months now. It hasn’t been the easiest 6 months either. I was in a constant mental battle with myself over it. Every month I would think about asking my PM Dr to put me back on the opiates, but then I tell myself just try it for one more month. I would try to justify to myself why I needed to go back on the other meds. I would suddenly get aches and pains all over. I could thing about my knees and they hurt lol. I got depressed and became anti social. I didn’t think I could get out of bed. I dint even want to do my laundry or take a shower. I thought I can’t live this way anymore. “I need my pain meds back.” The good news was that it got easier each month. For a while, I didn’t think the patch was even helping me. Then one month I lost my last 10mcg/hr patch it fell off somewhere. This was the moment when I realized that the patch had actually been working. Suddenly, I was in full withdrawal, well maybe not suddenly, but you know what I mean right? Soon all of my pain came back too and with a vengeance. Then I realized that what I was really missing from the opioid pills was that uphoric feeling like yeah “my pain is gone and I can do anything again!!!”So now, my pain had been gone or at least relieved. I just didn’t notice bc I was too busy wishing I still had my opioid.

          Now that I am less reluctant to the idea of Buprenorphinre, I can deal with which dose and route will best work for me. Obviously the patch was not working bc It kept falling off in the shower or outside exercising, so I have chosen to try the sublingual films with a fair increase in dosage.
          It really is working now. I don’t have any excuses anymore. Not that I don’t occasionally crave oxyi bc I do, but for me it was the psychological aspect that was holding me back. I really believed it was the physiological (Physical) pain relief that I was seeking.. I suppose psychological can become physical or vice-versa.
          Each month it has gotten a little easier than the last. My pain has become manageable, Yet never gone. My family is happier with me, my social life is improving along with my mental health. I am not saying that I am absolutely fine with the changes I have made bc it is a process. To unravel the trickyness of our brains to get something it wants. We have to find the desire to change. Change your Brain.
          You owe it to yourself to give it a try. Wipe the slate and start over with something new. It won’t hurt anymore than you are already. hurting. Give your pain management Drs a break and choose a different option. They are here to help you help yourself.

      5. Jeffrey Fudin,
        While it is a common misunderstanding, please make note that your understanding of this disease is not correct. It is not limited to causing pain only during menstruation, and has been found in every internal organ and anatomical structure including the spleen. (This is one of the reasons it’s so important to be evaluated by surgeons who have proper training in excising the disease – it can be destructive, sometimes causing individuals to lose kidneys, require total colostomy, thoracic endometriosis which can cause breathing problems, seizures if endometriosis is in the brain, and on and on.) Please consider reviewing more recent information on the disease. I recommend publications and citations on the website of The Center for Endometriosis Care in Atlanta, considered to be one of the top clinics in the world for treating this very dangerous disease.

        1. Amber, I have asked a couple of woman on here to collaborate with my daughter (who is a PharmD specializing in women’s health) to collaborate on a guest blog on this site. If you, or someone you know is articulate and interested in pursuing this, please let me know. You can email me at jeff@paindr.com. Thank you!

    2. this has hit the entire pain community sadly I was taking 30 mgs 3xs a day of extended release morphine with 15 mgs of short acting morphine I was able to live a functional life after years and years of fighting with Dr to please treat my pain which because I was so young they couldn’t believe a girl in her 20’s would have hip and spinal issues so they loaded me up on everything but a pain medication until I got slammed with migraines and it went down hill I dealt with full blown serotonin syndrome where I landed in ICU cardiac ICU was in two comas on life support in may of 2008 while stranded in an ICU room I made the decision to go off basically everything except the couple of meds I had been on for years I had almost two years of no pain no migraines and then my spine and hip started showing serious issues and I dealt with serotonin syndrome again never landed in ICU but the pain and dropping to the floor convulsing and screaming in pain terrified to go to the er it got to where it really progressed and I was running a fever my blood sugar dropped you couldn’t even touch me I was treated horrible at the hospital I was brought to and I was ignored and told to shut up by the nurses when it got to where I was over heating so bad I went over to where the ambulance doors open and they said because I left my room I was being discharged! This was also after they did 9 attempts to take blood refusing to change the IV port they were going to try for another three but I was screaming in pain you couldn’t even touch my skin. Needless to say they also decided to proceed to have the police come remove me off the property cause I asked for my cell charger and they said the called cab for me the police got my phone and I was kicked off the property at 5:3o am in shorts and a tank top in 35°s no cab came so I went over to the rite aide where I was starting to have trouble talking they called the cab and I went to the er on the other side of the city first thing they asked was to see my arms when I gave them my name and I was ignored a friend came and got me he took me to a different er out of the area and I collapsed in the waiting room they got me in a room I said what was going on best I could they gave me something and it made my whole body lock up and all’s I could do was scream in pain my poor friend didn’t know what to do they gave me something else I wasn’t able to talk my face was dropping to where I looked like I was possiblity having a stroke. The Dr and nurse said hers your paperwork you’re free to leave and my friend he had never spoken up and he was like she can’t even talk or make sense you need to treat her! They said we could leave or the police and security could escort us by the time I got home the entire side of my face was dropped all the way down anything I tried to say came out backwards my muscles were going nuts Ihe had to take me home and pray nothing bad happened overnight when my son’s dad got home and I started my meds again I got even worse we went to another er and I was diagnosed with serotonin syndrome which my PCP had kept insisting there was no way I had it after my second visit I refused to see him alone he was a horrible Dr. He refused to carry over the mow dose of pain meds I had for my back claiming he wasn’t going to be responsible for another junkie on the street. And if he caught me not taking the effexor I would be discharged well I was discharged after he got the er information that diagnosed me with the seretonin syndrome and was given a shot of pain meds and a bottle of Valium to take to help treat it. I was assaulted in 2010 and by 2011 I was finally taken seriously as of January 2017 everything I went for to get proper treatment and Drs that backed the treatment and said opiate pain medication Was an adiquit option for treatment since I didn’t agree with the alternative treatments . Suicide sent me to get on buprinephrine against how much I didn’t want to had said no for over two years. And it was just based on little information like how everyone bi knew on it abused it would steal it from each other and I had enough issues with the people who had addiction issues try and climb through my window and just out me through hell prior to being out all on morphine. But people who did nothing worng with severely painful issues and chronic pain conditions are left to suffer while illegal drugs pile over the border now. Pain patients are having to turn to the street or many have passed away it’s just amazing how people can’t see we are repeating the past They went after the weak first then mandates for kid to get vaccines which I now deal with a painful side effect that’s now life long from but states mandated everything for the kids and now they are going after us adults yet all the out breaks were all vaccine related or they were vaccinated and still hospitalized where we have treatments we don’t need a vaccine We let the government control health care and no one will fight for our country if they think they will fight for us people have a wake up call. I’ve been getting worse and worse on the buprinephrine health wise and side effects I have a day or so no pain then days I wish I didn’t exist. If I didn’t have all the issues and just got the pain relief I would be golden but I can even enjoy summer or late spring most of fall it’s a very horrible life especially when u have kids .

    3. I had endometriosis and PCOS from the time I was 14 years old. I was told I’d never have children on my own, I have 2. I was told having children usually helps clear up the endometriosis, yeah it got worse. I ended up getting a hysterectomy before I was 30 and it was the best decision I ever made. No more pain, no need for pain pills, I did have to jump through numerous hoops though because of my age my insurance did not want to cover it. Luckily for me I was able to have 2 children on my own first. I actually had a “doctor” attempt to deter my decision for the hysterectomy by saying “what if something happened to one of your kids? Wouldn’t you want to be able to have more?” Like really?! Anyway, sorry for rambling but surgery was my last resort. I was tired of taking pills that made me feel like a zombie yet if I didn’t have any of them the withdrawal was just as intense as a heroin withdrawal. Since opiates are basically synthetic heroin, and I refused to be a statistic. Bottom line surgery isn’t the answer for everyone but it was for me. If you haven’t considered it, it’s worth looking into.

  8. Been on Norco 10-325 3X daily for about 5 years for degenerate disc disease. Today I told the Dr I’m having a hard time with the Norcos only providing about 2 hrs of decent pain relief, therefore not getting lasting pain relief overall. My pain mng Dr. added Belbuca Film 600 mcg 2x daily to my three 10mg Norcos. Currently wondering if this level of Belbuca film will stretch my pain relief duration with the Norcos still being used every 4 hrs 3X daily? Or is the Belbuca at 600 mcg going to cancel out my pain relief from the 30mg daily of the Hydrocodone “Norcos?” Could this level (600mcg 2x daily) of Belbuca Film induce withdrawal systems from Norcos, even while still prescribed and taking them them? The whole idea was to provide a better whole day pain management system. Currently waiting to see if my insurance will pay for for the Belbuca before actually trying.

    1. Dont mix, how does your Dr not know bupe will throw you into precipitated w
      WDS, you’l wish u were dead, I’ve been tbrough it.

      If youbcan make it a week and not feel gorrible,just the pain but only if you have zero physical dependence you could take on top of BUPRENORPHINE .

      Ice heard of bupe (physically addicted) for pain, they are able to take norcos on top because bupe just blocks the norcos from attaching to opiate receptors. Some say they get relief. But they had to go bupe to hydros cause other way is asking for withdrawls worse than you know.

    2. I went all the way up thru to 900mcg of Belbuca. I got so sick of the flavor! It’s a minty flavor that after a few years u build up annoyance to especially when the medicine goes downhill in helping out at all. Gone back to Butrans patches. I’ve dealt with chronic pain since a car accident in 98 and a dr screwed me up in back surgery. Thanks to him…there is nothing that can be done except make me comfortable???Well with degenerative disc disease, narrowing of the spine, few discs have already fused together, plus I still have herniated discs, and arachnoiditis from the doctor letting me lose most of my spinal fluid after surgery. I got lucky and a nurse listened to me and I went back in for an emergency to come out worse then I went in. But thanks to the the state here it’s hard to get meds so you can have 100% pain relief. But Belbuca I say is a joke. It works for few hours after u take it. It DOESN’T last 12 hours. So watch out. N be careful and don’t be quick to trust doctors either. They are screw ups to.

    3. I take 600 mcgs twice a day of belbuca for my intense chronic pain for my degenerative disc disease in my entire spine, a couple herniated discs in my neck and lumbar spine and my Numerous bulging discs in my cervical thoracic and lumbar spine as well as my neck curving the wrong direction and scoliosis and lordosisas well as bad occipital neuralgia. I was on 4 percocet a day prior 5 325s. With the Percocet I didn’t have much of life still had lots of breakthrough pain and the pills weren’t giving lasting relief for even 3 full hrs. I started being belbuca at 75mcg and tapered up to the dose that worked for me which is 600mcg. I’m still limited in what I can do physically like I always will but I finally have better quality of ljfe. I was even able to ride a horse again for an hr which i missed so much along with most hobbies I lost with chronic pain. I can do most of them again for an amount of time I’m grateful for. I take the belbuca twice a day and have 30 Percocet a month up to 3 a day as needed for breakthrough pain I usually don’t even need it on a daily basis but depending what I do I do need it sometimes when I try to do too much. I am getting the most relief I’ve gotten in my decades of suffering with chronic pain. The belbuca doesn’t cause me uncomfortable side effects, I’m able to fully function, I haven’t had any issues of withdrawals as some ppl speak of. I take both together some days with no issues. No side effects just the pain relief. Chronic pain I swore was gonna be the death if me cause I lost everything that brought me joy. Now I have a more fulfilling life thanks to belbuca. If your looking for highs this isn’t the drug but it’s also why I think its a miracle so us Responsible and legitimate chronic pain sufferers can actually get relief and hopefully addicts won’t ruin this for us too. If ur looking for solely pain relief this med does wonders. Give it a chance.

  9. Ive been taking Butrans for about 8 months. I seemed to work until the last few days but my problem is every time i go in to give a urine sample my result comes back negative and nobody seems to understand why or can explain why Im getting a negative result

      1. PLEASE provide bio/dose chart conversion link: 5 mcg Butrans GREAT, severe skin burns. Tabs, sublingual + hydrochloride 2 mg/2x day GREAT. Tabs 2 mg/2x day sublingual SLEEPY. Film 75 mcg (RX 2x/day) quartered, 1 per 6-8 hours, still EXTREMELY SLEEPY, FATIGUE. (I start new RXs slowly) THANKS FOR YOUR HELP!

    1. It depends on when you started your Belbuca. They can’t pick up high levels if it has been a while since u first started it, Plus other meds can help push it out your system. That’s what I was told by someone in the lab. Cuz my dr drug tests every month. It has come up with nothing in my system at all -even though they know I take my meds faithfully.

    1. Well I took many different opiates for many years. CES and five spine surgeries have not been kind. Belbuca has proven more effective than any of them. Finding the proper dose seems to be the key. I have found less is more. I now only take it when I am dealing with an 8 or a 9. In fact I took a small amount today (150 mcg) and it has helped immensely.

    2. Before Suboxone, it took 200 mg. of tramadol to make my pain bearable, now taking two strips a day my pain is manageable but I have no energy, no appetite and no motivation to do anything, extremely tired and lay down all the time. Don’t feel it is the appropriate medicine for me, but anything is better than being in pain all the time, I still have some I have to live with, I have holes in the peritoneal membrane where the mesh didn’t stay after doctors lied and left me with mesh but no truth on my records, another death wish. don’t help her. I’d survived peritonitis after over 3 years without antibiotics. I think I’ve tried the subutex before and liked it better, don’t know if it would make a difference now.

  10. I used to take 90mg / day of morphine 60 er and 30 ir. Now I take 900mcg/day of Belbuca. Getting decent pain relief but doesn’t last 12 hours and still have a few days a week of breakthrough pain. I take Norco for that. Doctor says I can go to 1200mcg per day of belbuca. Would that help it last longer and less breakthrough pain? How does 1200 belbuca compare with 90mg morphine? I want to avoid a super high dose. Thanks.

    1. Jim, There is no evidence to validate at 1200mcg dose of Belbuca, although some doctors have prescribed Suboxone and related products off label for pain with good results, and the doses are higher then 900mcg of Belbuca.

      1. I am getting mixed information. My pain dr. says buprenorphine will block my oxycodone if prescribed at the same time. I have read studies that claim it has supra additive when combined. Can I take a low dose buprenorphine and still get relief from the oxycodone?

          1. It depends on the dosage form because each dosage form has a different percentage of absorption into the blood. The highest dose of Butrans (5mcg/hour, 5mg patch) is about equivalent to the lowest dose of Belbuca (75mcg/hour), although Belbuca is available in up to 900mcg buccal films. All of the buprenorphines available to opioid use disorder are moderate to high dose.

          1. My dr just started me on 300 belbucca and I was on a 5mg patch of .Question is ,if 5mg patch is equivalent to 75 mg belbucca,how many mg is in a 300 dose of the belbucca ? Thank you

        1. I was just prescribed the 12-hour patch. I’m currently taking oxycodone for incurable cervical spinal stenosis pain. I had researched the prescription and brought it to my PCP’s attention as an alternative. From my research and from discussing it with my PCP, once I begin with the patch, I can no longer take the oxycodone. That could create a dangerous life-threatening respiratory depression situation and possibly death. Please don’t take both without consulting your doctor or a second opinion if your doctor says that it will just bloke your oxycodone. I fear for your life!

        2. Hey so you need to take the bup before you take the oxycodone every day if you want the oxy to work as breakthrough. But if you’re on Oxy already and take the bup you could have withdrawal symptoms

      2. hi, Im researching this I find it fascinating, I have awful back pain issues,herniated disk,DDD,arthritus. mris to prove it all , my dr. has been unwilling to prescribe anything nor has the pain specialist near me. I do somtimes have access to bupenorphine and realize yes this helps me!! how can I find a dr. to work with me? should I just tell them that ? Im about to give up , on finding a good dr. that doesnt treat me as if Im full of it. 🙁 its been years and I am looking for a dr. willing to help me. Do I need to find a specific one? I feel like I keep reading conflicting info on this. Thankyou

        1. I suggest that you tell your primary care doctor that buprenorphine works. Many do not know that there are two FDA approved formulations for pain; the Butrans Patch and also Belbuca, neither of which require the special x-waiver for prescribing, which means anybody with a DEA license can prescribe these.

          1. Nicole, love your name! Good luck to you. I’m just starting the 150 film. After taking opioids for decades I was forced to a pain clinic where they one day took it all away. Mind you I have NEVER had a black mark. Now urine test and closely monitored. All the pain people are highly opinionated, meaning that if you take prescribed medications responsibly you are still a drug seeker and treated as so. We are all in the same druggy bowl. And they make you feel like a drug addict. I wish I would have been smart enough to be a white collar worker instead of a blue one with many body injuries. I have always spoke the truth which us more than I can say about some providers. Truth no matter what! I understand your pain and frustration. To the providers I say,, walk a mile in our shoes, come watch how we live. OH, sorry but as I’ve been told nobody cares how this is effecting us. I just want to be able to function daily. I could go on but best of luck to all..

          2. Anyone with a DEA license can prescribe, but most primary care physicians won’t do it. Pain management doctors only, most of which do not know what they are doing!

        2. Due to the extreme measures taken by the DEA based on faulty data provided by the CDC, it is difficult in some areas of the US to obtain opioid pain medications. However in most areas it has gotten easier to obtain medications for Opioid Use Disorder, OUD. Suboxone containing Buprenorphine n Methadone are the primary medications used in MAT programs for OUD. Now Buprenorphine is considered the “gold standard” for treating opioid addiction. Hence using Buprenorphine for pain gets the patient automatically associated with addiction, it’s incorrect but it’s the reality. This association can cause many difficulties in a patients life. (Adding a diagnosis field to the PDMP would help correct this issue). Understanding that association, some chronic pain patients have reported using the increased availability of MAT programs to obtain Buprenorphine products as well as Methadone. If you understand using a MAT program to get Buprenorphine will get you associated with addiction and this doesn’t concern you enough to prevent you from doing it, a MAT program might very well be a good source for you during these days of doctors refusing to prescribe pain medications.

        3. The ‘pain specialist probably wanted to do ‘interventional procedures’ in lieu of pain meds, am I correct? This makes the doctors more money than just prescribing med refills. Epidural steroidal injections: Were those suggested? AVOID. Run from all of those invasive procedures. They are dangerous and worthless.
          Call your insurance company and see if they can give you a list of board-certified pain management doctors. You’ll have to call them one by one, to see if they will prescribe opiates. Many won’t because of the ‘procedures’ that make them more money. At this point, with the overinflated opiate crisis, doctors realize they can make more money with invasive procedures.
          Finding someone who will prescribe opiates will be a challenge.
          Ummm, one last thing: How do you ‘sometimes’ have access to bupenorphine? It’s a controlled, Schedule 2, strong opiate that needs to be prescribed by an M.D………..?

      3. Hi, i was hoping you could help me out. I am currently on subutex 8 mg x 3 daily. It is not helping with my chronic pain at all and i am experiencing hot flashes on a daily basis. It is getting so bad, the pain and other feelings have made it where i do not leave my house. I have been on it for 7 months and has only gotten worse. My doctor wanted to switch to belbucca 300 mg x 3. However my insurance doesnt pay nearly as much towards it and i really cannot afford it, especially if its not going to work any better than subutex. Should i expect the same results or similiar? And i am still confused on if taking hydrocodone for breakthrough pain is an option? Any other advice or suggestions would be appreciated. Thank You

          1. If you were to take 3 150 mcg films (@ the same time) vs 1 450 mcg film would there be any difference in the effects of the belbuca? Thank you

          2. Brian, That has not been studied. I can tell you that it won’t be exact because the surface area exposed to the mucosal tissue will not be the same.

          3. Thank you for the previous response. Just a couple of other questions. If you were to place a 150 mcg patch inside your left cheek and the other inside your right cheek wouldnt that expose the patches to the same area of mucosal tissue as 1 300 mcg patch? Also could you explain how belbuca works differently than subutex? Besides the delivery method and dosage amounts. Thank you again.

          4. Theoretically you are absolutely correct, but it hasn’t been studied. Subutex works no differently than Belbuca, except the dosages and amount of drug entering the bloodstream are different.

          5. Thank you again for responding. Yet another question. I was prescribed 450 mcg belbucca 2 x per day and norco for breakthrough pain. If a person was prescribed 8 mg of subutex 3 x per day, would the norco have the same affect as the belbucca? Thank you again.

          6. Higher doses of buprenorphine as seen with Subutex allow less opioid receptors open to be occupied by the hydrocodone in Norco, and those receptors favor buprenorphne over Norco. There could be some benefit of Norco, but it will be much reduced compared to moderate dose Belbuca as you describe.

        1. Brian, Belbuca prescriptions can be obtained using a manufacturer’s coupon. Most people will pay $0 for the first month and $10-25 for subsequent months for at least up to a year depending on insurance and financial status. After putting off filling a script once I found out it was going to be $150 even with insurance, my PMD told me about their coupon program. Just google belbuca coupon or similar and you should find it.
          Good luck!

        2. Belbuca the first and only med that kills the chronic pain in my back and hip. My PC physician refused to give me any more Vicodin because his license would be at risk. He referred me to a pain clinic which gave me a virtual visit (phone) and prescribed Belbuca. I research it and was nervous about it but tried it anyway and suddenly I could walk. No breakthrough pain. I take it ever 12 hours. Magic but for one uncomfortable side effect: Terrible itching rash all over my body but I can handle it better than the pain.
          I was shocked that the phone visit was able to afford me such a med. I had been taking Vicodin for over a year which didn’t work well. Ask your dr for a referral to the pain clinic. How you answer their questions will determine the prescription for your pain.

      4. I am on Subutex 4mg QD for 4 years never missing a dose relapsing, My Doc retired suddenly with no notice during all this Covd19. So I just ran out and I’m terrified of the withdrawals. I know it’s not approved for opiod dependence, but wouldn’t the Butrans patch alleviate wds?

        1. It would not, because the doses are too low. Best bet to avoid withdrawal is to find a doctor that can prescribe it. During the interim, your primary care doctor can prescribe clonidine or lucemyra to blunt withdrawal symptoms.

  11. Someone told me that Belbuca reduces the pain management affect of Oxycodone. Is this a true statement?. I am in chronic pain and cannot have once pain medication reduce the affects of the other.If this is the case I will make my pain doctor stop prescribing it for me.

    1. If you are on large doses of oxycodone, buprenorphine cam cause oxycodone withdrawal. If you are on low doses of oxycodone for breakthrough pain, they can work well together.

      1. I have advanced cervical disc disease, with all the abuse and illegal drug use they are scrambling us. The fear I have is we are going to give Bulbuca films 300 as a replacement for my 12 morphine 15 3 times a day. The doctor states we will keep oxycodone for break through at this time 4 time’s 20 mg. After reading this I am terrified at reaction.

        1. Doc,
          Will the dose set up of, 300 belbuca and 20 mg oxycodone every 6 hours cause problems? The belbuca is replacing 3 x 15 morphine.

        2. Lorrie, I realise your comment is a few months old and this will likely not help you, but I’m posting it as a reference for others who may come across this:
          I went from ~80mg per day Norco (hydrocodone) and 200mg Tramadol ER to 300mg Belbuca with the Norco in reserve for breakthrough pain. FYI Norco/hydrocodone is a 1:1 Morphine Milligram Equivalent, so 80mg Norco per day is equivalent to 80mg morphine per day.
          I only experienced very mild potential withdrawal symptoms upon starting the Belbuca, and it’s even possible that they aren’t even withdrawal symptoms but just side effects of the Belbuca, as many of the listed side effects are similar to a mild withdrawal, such as mild headaches, intermittent joint discomfort (it will present in my left foot arch, my left hand knuckles, and my left ribs near where the apex of my bicep rests that comes and goes from each location once or twice a day, lasting about 5 minutes), a feeling of being in a bit of a “daze”, and some daytime restlessness. I have been able to drop from 80mg Norco daily to maybe 5-20mg daily, as the Belbuca is much more practical for managing the pain floor than the Tramadol was and I don’t need as much of the hydrocodone to compensate.
          The only downside is that the mild headaches, intermittent joint pain, and mental fog have lasted a bit longer than I would have expected, but they are definitely preferable to the amount of lower spine and SI pain I was living with previously, even with the Norco/Tramadol combo.
          So, is it withdrawal? Maybe. But at the doses I came from, it’s not the full blown “unable to sleep for days and hating life and everything about it” withdrawal that I have gotten a few times previously over the years when the pharmacies ran out of my medications due to shortages – it’s tolerable during the day (I’m able to work and take care of my kids without lashing out), and I have been sleeping just fine.

          1. Wow, so many of you in polypharmacy. This is not good, especially with high doses of ER opiates.

        3. I’m so confused. My pain doctor is crazy, but I’m at his mercy and he knows that. I have lupus and cancer. I have been on oxycodone 10 mg for years. Now he has change my prescription to oxycodone 10 three times a day plus Belbuca 300mcg and I feel both medications are contradicting and canceling each other out. Do you have any answers about that? I’m just concerned if I take the Belbuca and it doesn’t and then I take my oxycodone will it not work? I’m just lost on this loss on this whole thing. I would love any suggestions and comments about this if you happen to know any and would like to share.

          1. Krista, While titrating Belbuca upwards, it’s okay to use an as needed traditional opioid. If you are not responding and the plan is to include Belbuca in the regimen, your doctor should increase the Belbuca with plans to discontinue the oxycodone. Using both together on a regular basis is unusual, but I’ve seen this done by some providers.

      2. Hello my boy friend is taking belbuca 300mcg x two every 12 hours I’m wondering if there is a different place besides the cheek u can put it I’ve looked online and have found nothing but the cheek it is sticking to his teeth plz help ?

        1. Melissa, I’m not sure I understand the dose correctly. If he’s using two Belbuca Films per dose at 300mcg each, he should have a 600mcg Film to use for each dose. or, perhaps I’m misunderstanding and he is only using 300mcg each 12 hours. In any case, when placing the films on, the yellow side goes against the cheek. It needs to be placed against the cheek adjacent to the gum line beneath the teeth – it should be held there for 30 seconds. If it’s done correctly there should not be an issue.

          1. The same thing happens to me. I place it inside my cheek, hold it, & it sticks to my teeth every time

          2. I know this is an old post but for anyone reading it for info proposes, If you have false teeth it WILL STICK to your teeth. No way around it.

        2. I find the Belbuca patch does stick to teeth so I move it to my gums with my tongue before it melts. It’s okay. Still works.

      3. Hello Jeffery..I have a question. I’m currently taking 8mg of Buprenorphine every 12hrs. Can I take 10mg Norco for breakthrough pain? Will it help with my pain?

        1. Jennifer,

          Doctors do sometimes prescribe traditional opioids for breakthrough pain for persons taking buprenorphine, but if you can use a non-opioid that is a safer option. See Webster L, Gudin G, Raffa RB, Kuchera J, Rauck R, Fudin J, Adler J, Mallick-Searle T. Understanding Buprenorphine for Use in Chronic Pain: Expert Opinion. Pain Medicine. 2020.


    1. I can tell you to research it, lol. I don’t trust interventional procedures. They are mostly worthless and dangerous.

  12. I have taken subutex for 4 years now and have been weaning myself off from 32 mg a day to 6mgs a day. My doctor prescribed tyenol 3’s with codeine for pain, so my question is.. is it okay to both together or will I get sick with withdrawal? Thank you!

      1. So taking 150 mcg belbucca every 12 hours. Because I have malabsorption issues. No colon. Pills sometimes don’t work because of this. I am Taking 10 mg oxycodone IR for break through pain. Everytime I pick them up. The pharmacist asks me if my doctor knows that these basically cancel each other out. Is this true? Or is there a way to work them together. I don’t understand all these people telling me different things. Severe Crohns, with bone and muscle pain. 30 yrs. looking for answers.? TIA

        1. They do not cancel each other out. But, belbuca has a higher binding affinity to the mu-receptors, which is where both of these drugs work. There are always some unoccupied receptors that can bind with oxycodone, but less are available when a person is also usingh Belbuca. Therefore oxycodone will likely be less effective. Oxycodone does not lessen the effect of Belbuca. It wouold be dangerous to stop the Belbuca and just continue the oxycodone at this point, because it couold result in an overdose. If these drugs are used together they must be prescribed and titrated very carefully by a knowlwedgeable clinician.

          1. Just wanted to put my 2¢ in, on pain mgt for many years, oxy to hydromorphone. On 80 mg Prozac for MDD, now on 600 mcg belbuca bid. Went from not being able to walk to having tolerable pain. To me it is working great so far. Also can’t use NSAID meds, CHF on top of the spine issues. Don’t even miss ’em. For me belbuca works great.

    1. Hello, I switched from MS Contin to Belbuca about 6 months ago and continue to take Norco for break through pain. I really like Belbuca as I feel the medication lasts longer and there are fewer up’s and down’s. My only issue is I feel more fatigued during the day on this medication. I was hoping to increase Belbuca so I could reduce Norco but I’m concerned about being more tired. Are you aware If a higher dosage would increase fatigue, and if so is it something that generally gets better with time?

  13. Does a physician need the certification required for prescribing Suboxone/Subutex in order to prescribe belbucca? I have a history of opiate addiction and was treated with belbucca for my chronic back pain with good results…I have moved and have not yet found a new pain management doctor and my primary physician is saying they cannot prescribe me belbucca bc they are not certified to do so. I feel like they are just afraid of doing it and or not knowledgeable about it. Also I see that Suboxone is being prescribed off label for pain…in those instances does the physician have to have the certification? I am a part of the recovery community and support the idea that ANY Dr should be able to prescribe Suboxone…it needs to be way more accessible in this age of opiod crisis.

    1. Kim, Any doctor, NP, PA, or other prescriber with a DEA license can prescribe Belbuca or Butrans without a special certification or X-waiver. Additionally, they can all prescribe Suboxone “OFF-LABEL” if they are prescribing for pain, which also does not require anything special.

      1. Hello,

        I have been taking Tramadol 50mg every 8 hours for two years and had Belbuca 150mg twice daily for 5 days the. 300 mg twice daily introduced. I am under the impression that both drugs are partial mu agonists. Will they not cancel each other out when taken together. Also I saw a potential risk of seizures. My doctor kept me on tramadol for breakthrough pain.

        1. They will not cancel each other out. Most of tramadol’s activity is from reuptake blockade of norepinephrine and serotonin, not it’s very weak opiate activity. Buprenorphine, although a partial agonist, has much higher binding for the opiate receptor compared to tramadol and it works in many other ways at the spinal level and in the brain. Bottom line is that buprenorphine is far nor effective and had a better side effect profile compare to tramadol. I can’t speak to the safety of using both together for YOU because I don’t know your medical history or what other drugs you take, all of which could be factors on your unique case.

          1. Thank you so much that is very helpful. I just wanted to make sure they wouldn’t be fighting over the same receptor and that they could work together in multiple receptors but it sounds like the Tramadol helps more
            On a neurotransmitter ascending pathway anyway.

  14. 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. Hi, FINALLY, a person with whom i can relate to; while working at a Biotech co from Jan 2010, I was exposed to elemental mercury toxicity poisoning due to inhalation or heavy metal poisoning. I didn’t realize until 2016 that it was the cause of my rapid decline and multiple horrific illnesses all along being called a hypochondriac until I was diagnosed with small nerve fiber neuropathy/peripheral neuralgia. Right away the 10mcg Butrans patch stopped 8 years of horrific nighttime neuropathy. I am also on 20mg of percocet daily, which my doctor upped to 40mg daily without my knowledge and I still have severe back pain, lol!!! I had a headache today, (not unusual) but also felt itchy and thought that my pharmacist may have given me Vicodin on accident and that is why I had looked at the bottle. I had the 10mg pills x 4 last month too and had no idea? Chronic pain is the worst. Lucky for me, I have a paradoxical effect to meditation so as I do not crave it or get euphoric from it. I just need it to relieve pain, UGH! OH, I use CVS Fluticasone Propionate Nasal spray on the spot of skin prior to placing the Butrans patch on and it absolutely has been a lifesaver, no more blistering.

  15. 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.

      1. How long after the last opiate dose (Norco, 7.5/325 in my case) is it okay to take the Belbuca? I don’t want to risk withdrawal or my Norco losing effectiveness. My doctor recommended me taking the Belbuca morning and night (12 hours apart) and taking my regular Norco TID for breakthrough pain.

  16. 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.

  17. 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.

  18. 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?

      1. I know that feel comfortable taking the drug that I’m all done b u p r e n o r p h i n e AND NALOXONE because they have an effect on my thyroids and my blood pressure and there are two big issues I worry about so I think that I would be better off back on my Percocets three times a day 7 point 3.25 I keep reading High easy it is to OD of the medicine the medicine we talkin about why would I anybody want to take something that you can OD off quick I would like an answer please

  19. 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

      1. Hi, I have lyme disease also. You can attribute your horrible spine (minus the scolios to that). I sympathize. The car accident reaggravated your lyme. When lyme is aggravated opiates are useless. You actually need to calm down your CNS and opiates while they may depress the CNS they do not do that with lyme disease at all especially if you have neurological lyme disease. I have told my doctors this many times. Have you considered Ketamine therapy? It will help reset your CNS. It’s something to discuss with your doctor at your next appointment. I haven’t tried it yet because currently everything is copasetic.

  20. 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!

          1. Just don’t know???? I’m 56, been taking hydocodone 10/325 for eight years from primary care due to a significant back injury . Now I may be looking at rotator cuff surgery. Due to the opioids crisis and laws, my doctor has sent me to pain management. They are calling in buprenrophine
            Which I will try, however I seem to have a fairly high tolerance to pain medication
            I’ve managed my pain just fine for the last 8 years. This scares me for all the people in pain, who may have to find different alternatives

  21. 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.

        2. Sue, I know I’m replying to a post you made well over a year ago but I just wanted to say that I hope you’ve found some relief. Your description of your ailments are almost mine exactly! It almost seemed like I had written it myself. As of today, I’ve just started taking belbuca 150. This first dose hasn’t helped a bit…..

  22. 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.

  23. 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.

  24. 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.

      1. The cost of Belbuca is over $600 dollars per scrips of 60 patches.
        It helps the chronic pain for sure but the expense is unreal.

  25. 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.

    1. Does subutex cause testosterone issues? I started taking this med 6 months ago. I already had EXTREME deficiency and have gained close to 50 pounds mainly in my chest and stomach. Also i really lack energy and have 0 sex drive. Could this be due to the subutex?

  26. 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

  27. 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.

  28. 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.

  29. 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.

  30. 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…

  31. 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.

    2. I am getting excruciating headaches and I feel exhausted everyday on Belbuca 175mg 2 x a day, I sweat all day long and get a sweezing feeling in my chest, I can’t sleep. But it does help the pain. Help. What to do? This really does suck if there weren’t so many side effects I’d want to stay on it. Any advice Doc?

      1. Susan, Do you mean one 75mcg buccal patch twice daily? They don;t come in 175mcg. If you were recently on a full agonist opioid like hydrocodone, oxycodone, morphine, etc, at moderate doses, you may be experiencing withdrawal symptoms, not adverse reaction to buprenorphine itself. If that’s the case, a slower titration over to Belbuca might help, or a higher dose of Belbuca might help. You should discuss these possibilities with your doctor and not make any adjustments without close supervision and the advice of your prescriber.

  32. 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.

  33. 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!

  34. 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!

  35. 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.

  36. 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!

  37. How many does should I have the Butrane Patch off before getting the Morphine Pain Pump Implanted?

  38. 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

  39. 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 .

  40. 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.

  41. 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!


          1. Hi! Long history w/ DAILY chronic pain due to RA, Lupus, Sjogrens, mixed connective tissue, total TMJ joint replacement from RA eroding 5mm of my condyles in jaw. I’m only 48, diagnosed 10 yrs ago happened overnight! Was in best physical shape, skated in a roller derby team, worked 12-13 hrs daily, single mom!
            I describe this happening as literally having the rug yanked out from under me! Still struggling to find new normal as I’m NOT a person who enjoys being in the house 24/7. In fact I hate it! My hands have such severe radial deviation? Hope I got that rt. I can no longer work. Stylist& makeup artist who was extremely busy & loved working. Everything I did for a living either required long days of standing, hovering over a shampoo bowl & constantly having a blow dryer in my hands.
            Old PM doc left & went to practice @ the local VA. So, I had to find a new doc. This was a nightmare. I was taking 30mgs opana 2x’s daily, 4 mgs of hydromorphon 3-4x’s daily for breakthrough. 50 mgs trazodone @ bedtime. Xanax 2x’s daily for severe panic attacks(blue ones can’t remember mgs) Adderall 30 mgs 2x’s daily for adult ADHD& severe fatigue.
            NewPM consult- wanted me to take clonodine& get off all meds for pain , 3 week taper! I DONT KNOW HOW PPL CAN DO THIS TO THEMSELVES! I mean using drugs illegally & withdraw to repeat that nightmare over & over again,
            I was a compliant patient nvr having a bad urine. Nvr smoke a cigarette in my life & only had drinks if I went out & it was 2-3 drinks tops IF I even went anywhere. I don’t drink @ all since I nvr go out at all!! I went thru worst withdrawals. My then 12 yr old was the only person I had to help take care of me! She should’ve nvr had to carry that burden! She’s had very negative lasting effects & constantly worries if I’m going to die. She’s now 17. Found yet another doc after not wanting to see the doc who in my opinion should nvr should’ve became a doc much less PM. Many said w/ my health issues a rapid unsupervised detox could’ve been deadly. Opana was pulled off shelf, put me in MS Contin, no help @ all. 25mcg fentanyl w/ Norco every 23 hrs. Nope, Fentanyl 50mcg for 3 yrs no increase despite many days unable to do ANYTHING pains so bad! Forgot to add have tried most all DEMARD therapy. Severe allergic reactions including analysis so I can’t do any of that as per my Rheum, bern w/ her since day 1! This pain doc wants me on 150mcg Belbuca cutting fent patches in 1/2 changing every 4 days not 3. Pharm wouldn’t fill Belbuca until I should’ve ran outta patches. This wouldn’t allow any taper from Fent at all. Last fent patch on now finally Pharm called Belbuca can be picked up haven’t started it scared to go thru yet another unnecessary withdrawals as now I’ll have no help! Daughter works 2 crap jobs to help w/ bills.
            Going see Pysh & rheum today. Any advice on transition from Fent 50mcg to Belbuca 150 mcg 2x’s daily. I’m calling doc & see what they say but in Louisiana Pharmacists have final say over PM doc when to fill even though this was a med change after 3 yrs & always use that same pharm.

            Any advice would be appreciated & sorry for long backstory thought u should have all information!

          2. Lisa, I’m sorry for all the problems you’ve had to endure. The case is way to complicated to evaluate on a forum like this. If your doctors are willing to work collaboratively, I’d be happy to offer a virtual consult if I had access to the records.

  42. 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.

  43. 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.

  44. 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.



        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.

        1. 300mcg of Belbuca is considered a low to moderate dose, considering the maximum dose of Belbuca is 900mcg twice daily. Remember too that different formulations of buprenorphine are available in even greater doses (Suboxone, Bunavail, etc). At the end of the day, much of dosing comes down to patient tolerability and efficacy (some patients require very little dosing for effectiveness, while others may require higher ones)!

  45. 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.

  46. 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

  47. 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.

  48. 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.”

    1. In the early days, some people in treatment facilities injected Burpenex into “gummy bears” as an early form of “subutex.” /quote
      [Shock] but what about the children?? Clearly they had this in mind all the time Ha, Man. If people knew how much this stuff actually costs they would know, no one’s going to be putting it in random kids’ halloween candy. I didn’t know about the gummy bear thing. The history of medication, including various routes of transmission, it’s all fascinating! (And informative of course. I’m not here just for fun, but it does help the .. medicine go down?.)

  49. 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!

        10. Concerned Reader: You are wrong. You should try to avoid announcing what YOU think people’s doctors will “NEVER” do. It’s so very rarely helpful. Best to you.

      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.

      2. Dear anonymous,

        Only products with buprenorphine& nalaxon have a wait time to stop opioids before starting .example: suboxene . It is the nalaxon that causes withdrawals if opioids have not cleared out of your system.

        buprenorphine Only products such as butran or belbuca can be taken with opioids, no wait time. These meds do not contain nalaxone.

        Suboxene & butran are two different meds but both contain buprenorphine.

        I take belbuca twice a day with norco 10mg x 4 a day with no issues .

        1. Danielle, This is not true – both naloxone and buprenorphine alone or combined could cause withdrawal from traditional opioids. Both are more highly bound to mu receptors compared to traditional opioids.

  50. 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


  51. 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.

  52. 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.

  53. 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.
            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.

  54. 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.

  55. 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

  56. 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

  57. 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?

  58. 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.

  59. 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

    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.

  60. 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?

  61. 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?

  62. 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.

  63. 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.

  64. 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.

  65. 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. Generally you should be on than oxycodeone 60mg per day and it could be on an as needed basis while starting the Butrans depending on what your doctor has prescribed and allowed.

      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.

  66. 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?

  67. 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.

  68. 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.

  69. 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!

  70. 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).

  71. 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?

  72. 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.

  73. 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.

  74. 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.

  75. 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. Doug, You should be through the withdrawal symptoms in a week to 10 days. In the meantime, your doctor could prescribe lofexideine or clonidine to mitigate withdrawal symptoms.

      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

  76. 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

  77. 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.

  78. 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.


    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 http://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 http://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.

        1. Karin,

          The easiest opioids for the liver to metabolize are morphine, hydromorphone, oxymorphone, tapentadol, and levorphanol. I’d say tapentadol is your safest option here.

  80. 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.

  81. 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

  82. 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?


    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.

  83. 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.

  84. 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


    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!

  85. 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

  86. 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


      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.

  87. 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.


      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.

  88. 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

  89. 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

  90. 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

  91. 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.

  92. 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?


  93. 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?

  94. 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.

  95. 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.

  96. 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.

  97. 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. I was on 4 325/10 percot a day. He switched me to the butrans patch20mcg a day. Can i take a percot for break through pain

    2. 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.

    3. 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.

    4. 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.❤

    5. 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,