Butrans (buprenorphine) for Chronic Pain: Side Effects & Dosage

Generic drug: buprenorphine

Brand name: Butrans

What is Butrans (buprenorphine), and how does it work?

Butrans (buprenorphine) is a prescription medicine used to treat the symptoms of Chronic Severe Pain. Butrans may be used alone or with other medications.

Butrans belongs to a class of drugs called Opioid Analgesics; Analgesics, Opioid Partial Agonist.

It is not known if Butrans is safe and effective in children younger than 18 years of age.

What are the side effects of Butrans?

WARNING

ADDICTION, ABUSE and MISUSE; LIFE-THREATENING RESPIRATORY DEPRESSION; ACCIDENTAL EXPOSURE; NEONATAL OPIOID WITHDRAWAL SYNDROME; and RISKS FROM CONCOMITANT USE WITH BENZODIAZEPINES OR OTHER CNS DEPRESSANTS

Addiction, Abuse, and Misuse

Butrans
exposes patients and other users to the risks of opioid addiction, abuse, and
misuse, which can lead to overdose and death. Assess each patient’s risk prior
to prescribing Butrans, and monitor all patients regularly for the development
of these behaviors and conditions.

Life-Threatening Respiratory Depression

Serious, life-threatening, or fatal respiratory depression may occur with use of
Butrans. Monitor for respiratory depression, especially during initiation of
Butrans or following a dose increase. Misuse or abuse of Butrans by chewing,
swallowing, snorting or injecting buprenorphine extracted from the transdermal
system will result in the uncontrolled delivery of buprenorphine and pose a
significant risk of overdose and death.

Accidental Exposure

Accidental exposure to even one dose of Butrans, especially in children, can
result in a fatal overdose of buprenorphine.

Neonatal Opioid Withdrawal Syndrome

Prolonged use of
Butrans during pregnancy can result in neonatal opioid
withdrawal syndrome, which may be life-threatening if not recognized and
treated, and requires management according to protocols developed by neonatology
experts. If opioid use is required for a prolonged period in a pregnant woman,
advise the patient of the risk of neonatal opioid withdrawal syndrome and ensure
that appropriate treatment will be available.

Risks From Concomitant Use With Benzodiazepines Or Other CNS Depressants

Concomitant use of opioids with benzodiazepines or other central nervous system
(CNS) depressants, including alcohol, may result in profound sedation,
respiratory depression, coma, and death.

Reserve concomitant prescribing of
Butrans and benzodiazepines or other CNS depressants for use in patients for whom alternative treatment options are inadequate.
Limit dosages and durations to the minimum required.
Follow patients for signs and symptoms of respiratory depression and sedation.

Butrans may cause serious side effects including:

weak or shallow breathing,
deep sighs,
snoring that is new or unusual,
breathing that stops during sleep,
chest pain,
fast heart rate,
seizure,
lightheadedness,
blisters, swelling, severe irritation where the patch was worn,
nausea,
vomiting,
loss of appetite,
dizziness,
feeling weak or tired,
upper stomach pain,
dark urine,
clay-colored stools,
yellowing of the skin or eyes (jaundice),
agitation,
hallucination,
fever,
sweating,
shivering,
muscle stiffness,
twitching,
loss of coordination, and
diarrhea

Get medical help right away, if you have any of the symptoms listed above.

The most common side effects of Butrans include:

constipation,
nausea,
vomiting,
headache,
dizziness,
drowsiness,
tiredness, and
redness, itching, or rash where the patch was worn

Tell the doctor if you have any side effect that bothers you or that does not go away.

These are not all the possible side effects of Butrans. For more information, ask your doctor or pharmacist.

Call your doctor for medical advice about side effects. You may report side effects to FDA at 1-800-FDA-1088.

Does Butran cause addiction or withdrawal symptoms?

Drug Abuse And Dependence

Controlled Substance

Butrans contains buprenorphine, a Schedule III controlled substance.

Abuse

Butrans contains buprenorphine, a Schedule III controlled substance with an abuse potential similar to other Schedule III opioids. Butrans can be abused and is subject to misuse, addiction and criminal diversion. The high drug content in extended-release formulations adds to the risk of adverse outcomes from abuse and misuse.
All patients treated with opioids, including Butrans, require careful monitoring for signs of abuse and addiction, since use of opioid analgesic products carries the risk of addiction even under appropriate medical use.
Prescription drug abuse is the intentional non-therapeutic use of a prescription drug, even once, for its rewarding psychological or physiological effects.
Drug addiction is a cluster of behavioral, cognitive, and physiological phenomena that develop after repeated substance use and includes: a strong desire to take the drug, difficulties in controlling its use, persisting in its use despite harmful consequences, a higher priority given to drug use than to other activities and obligations, increased tolerance, and sometimes a physical withdrawal.
“Drug-seeking” behavior is very common in persons with substance use disorders. Drug-seeking tactics include emergency calls or visits near the end of office hours, refusal to undergo appropriate examination, testing, or referral, repeated “loss” of prescriptions, tampering with prescriptions, and reluctance to provide prior medical records or contact information for other treating healthcare providers(s). “Doctor shopping” (visiting multiple prescribers to obtain additional prescriptions) is common among drug abusers and people suffering from untreated addiction. Preoccupation with achieving adequate pain relief can be appropriate behavior in a patient with poor pain control.
Abuse and addiction are separate and distinct from physical dependence and tolerance. Healthcare providers should be aware that addiction may not be accompanied by concurrent tolerance and symptoms of physical dependence in all addicts. In addition, abuse of opioids can occur in the absence of true addiction.
Butrans, like other opioids, can be diverted for non-medical use into illicit channels of distribution. Careful record-keeping of prescribing information, including quantity, frequency, and renewal requests, as required by state and federal law, is strongly advised.
Proper assessment of the patient, proper prescribing practices, periodic re-evaluation of therapy, and proper dispensing and storage are appropriate measures that help to limit abuse of opioid drugs.

Risks Specific To The Abuse Of Butrans

Butrans is intended for transdermal use only.
Abuse of Butrans poses a risk of overdose and death. This risk is increased with concurrent abuse of Butrans with alcohol and other substances including other opioids and benzodiazepines.
Intentional compromise of the transdermal delivery system will result in the uncontrolled delivery of buprenorphine and pose a significant risk to the abuser that could result in overdose and death.
Abuse may occur by applying the transdermal system in the absence of legitimate purpose, or by chewing, swallowing, snorting, or injecting buprenorphine extracted from the transdermal system. Parenteral drug abuse is commonly associated with transmission of infectious diseases such as hepatitis and HIV.

Dependence

Both tolerance and physical dependence can develop during chronic opioid therapy. Tolerance is the need for increasing doses of opioids to maintain a defined effect such as analgesia (in the absence of disease progression or other external factors). Tolerance may occur to both the desired and undesired effects of drugs, and may develop at different rates for different effects.
Physical dependence is a physiological state in which the body adapts to the drug after a period of regular exposure, resulting in withdrawal symptoms after abrupt discontinuation or a significant dosage reduction of a drug.
Withdrawal also may be precipitated through the administration of drugs with opioid antagonist activity (e.g., naloxone, nalmefene), or mixed agonist/antagonist analgesics (e.g., pentazocine, butorphanol, nalbuphine).
Physical dependence may not occur to a clinically significant degree until after several days to weeks of continued opioid usage.
Do not abruptly discontinue Butrans in a patient physically dependent on opioids.
Rapid tapering of Butrans in a patient physically dependent on opioids may lead to serious withdrawal symptoms, uncontrolled pain, and suicide.
Rapid discontinuation has also been associated with attempts to find other sources of opioid analgesics, which may be confused with drug-seeking for abuse.
When discontinuing Butrans, gradually taper the dosage using a patient-specific plan that considers the following: the dose of Butrans the patient has been taking, the duration of treatment, and the physical and psychological attributes of the patient.
To improve the likelihood of a successful taper and minimize withdrawal symptoms, it is important that the opioid tapering schedule is agreed upon by the patient. In patients taking opioids for a long duration at high doses, ensure that a multimodal approach to pain management, including mental health support (if needed), is in place prior to initiating an opioid analgesic taper.
Infants born to mothers physically dependent on opioids will also be physically dependent and may exhibit respiratory difficulties and withdrawal signs.

QUESTION

Medically speaking, the term “myalgia” refers to what type of pain?
See Answer

What is the dosage for Butrans?

Important Dosage And Administration Information

Butrans should be prescribed only by healthcare professionals who are knowledgeable in the use of potent opioids for the management of chronic pain.

Butrans doses of 7.5, 10, 15, and 20 mcg/hour are only for use in patients who are opioid experienced and in whom tolerance to an opioid of comparable potency has been established. Patients who are opioid-experienced are those receiving, for one week or longer, daily opioid doses up to 80 mg/day of oral morphine or an equianalgesic dose of another opioid.

Use the lowest effective dosage for the shortest duration consistent
with individual patients treatment goals.
Initiate the dosing regimen for each patient individually, taking into
account the patient’s severity of pain, patient response, prior analgesic
treatment experience, and risk factors for addiction, abuse, and misuse.
Monitor patients closely for respiratory depression, especially within
the first 24-72 hours of initiating therapy and following dosage increases
with Butrans.
Instruct patients not to use Butrans if the pouch seal is broken or the patch is cut, damaged, or changed in any way and not to cut
Butrans.
Instruct patients to avoid exposing Butrans to external heat sources,
hot water, or prolonged direct sunlight.

Butrans is for transdermal use (on intact skin) only. Each Butrans patch is intended to be worn for 7 days.

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What drugs interact with Butrans?

Table 5 Includes clinically significant drug interactions with Butrans.

Table 5: Significant Drug Interactions with Butrans

Benzodiazepines

Clinical Impact:
There have been a number of reports regarding coma and death associated with the misuse and abuse of the combination of buprenorphine and benzodiazepines. In many, but not all of these cases, buprenorphine was misused by self-injection of crushed buprenorphine tablets. Preclinical studies have shown that the combination of benzodiazepines and buprenorphine altered the usual ceiling effect on buprenorphine-induced respiratory depression, making the respiratory effects of buprenorphine appear similar to those of full opioid agonists.

Intervention:
Closely monitor patients with concurrent use of Butrans and benzodiazepines. Warn patients that it is extremely dangerous to self-administer benzodiazepines while taking
Butrans, and warn patients to use benzodiazepines concurrently with
Butrans only as directed by their physician.

Benzodiazepines and Other Central Nervous System (CNS) Depressants

Clinical Impact:
Due to additive pharmacologic effects, the concomitant use of benzodiazepines or other CNS depressants, including alcohol, can increase the risk of hypotension, respiratory depression, profound sedation, coma, and death.

Inten’ention:
Reserve concomitant prescribing of these drugs for use in
patients for whom alternative treatment options are inadequate.
Limit dosages and durations to the minimum required. Follow patients
closely for signs of respiratory depression and sedation.

Examples:
Benzodiazepines and other sedatives/hypnotics, anxiolytics, tranquilizers, muscle relaxants, general anesthetics, antipsychotics, other opioids, alcohol.

Inhibitors of CYP3A4

Clinical Impact:
The concomitant use of buprenorphine and CYP3A4 inhibitors can increase the plasma concentration of buprenorphine, resulting in increased or prolonged opioid effects, particularly when an inhibitor is added after a stable dose of
Butrans is achieved.
After stopping a CYP3A4 inhibitor, as the effects of the inhibitor
decline, the buprenorphine plasma concentration will decrease, potentially resulting in decreased opioid efficacy or a withdrawal syndrome in patients who had developed physical dependence to buprenorphine.

Inten’ention:
If concomitant use is necessary, consider dosage reduction of
Butrans until stable drug effects are achieved. Monitor patients for respiratory depression and sedation at frequent intervals. If a CYP3A4 inhibitor is discontinued, consider increasing the
Butrans dosage until stable drug effects are achieved. Monitor for signs of opioid withdrawal.

Examples:
Macrolide antibiotics (e.g., erythromycin), azole-antifungal agents (e.g. ketoconazole), protease inhibitors (e.g., ritonavir)

CYP3A4 Inducers

Clinical Impact:
The concomitant use of buprenorphine and CYP3A4 inducers can
decrease the plasma concentration of buprenorphine, potentially resulting in decreased efficacy or onset of a withdrawal syndrome in patients who have developed physical dependence to buprenorphine.
After stopping a CYP3A4 inducer, as the effects of the inducer
decline, the buprenorphine plasma concentration will increase, which could increase or prolong both therapeutic effects and adverse reactions and may cause serious respiratory depression.

Intervention:
If concomitant use is necessary, consider increasing the Butrans dosage until stable drug effects are achieved. Monitor for signs of opioid withdrawal.
If a CYP3A4 inducer is discontinued, consider Butrans dosage reduction and monitor for signs of respiratory depression.

Examples:
Rifampin, carbamazepine, phenytoin

Serotonergic Drugs

Clinical Impact:
The concomitant use of opioids with other drugs that affect the serotonergic neurotransmitter system has resulted in serotonin syndrome.

Intervention:
If concomitant use is warranted, carefully observe the patient, particularly during treatment initiation and dose adjustment. Discontinue
Butrans if serotonin syndrome is suspected.

Examples:
Selective serotonin reuptake inhibitors (SSRIs), serotonin and norepinephrine reuptake inhibitors (SNRIs), tricyclic antidepressants (TCAs), triptans, 5-HT3 receptor antagonists, drugs that affect the serotonin neurotransmitter system (e.g., mirtazapine, trazodone, tramadol), certain muscle relaxants (i.e., cyclobenzaprine, metaxalone), monoamine oxidase (MAO) inhibitors (those intended to treat psychiatric disorders and also others, such as linezolid and intravenous methylene blue).

Monoamine Oxidase Inhibitors (MAOIs)

Clinical Impact:
MAOI interactions with opioids may manifest as serotonin
syndrome or opioid toxicity (e.g., respiratory depression, coma)

Intervention:
The use of Butrans is not recommended for patients taking MAOIs or within 14 days of stopping such treatment.

Examples:
phenelzine, tranylcypromine, linezolid

Mixed Agonist/Antagonist Opioid Analgesics

Clinical Impact:
May reduce the analgesic effect of Butrans and/or precipitate withdrawal symptoms.

Intervention:
Avoid concomitant use.

Examples:
butorphanol, nalbuphine, pentazocine

Muscle Relaxants

Clinical Impact:
Buprenorphine may enhance the neuromuscular blocking action of skeletal muscle relaxants and produce an increased degree of respiratory depression.

Intervention:
Monitor patients receiving muscle relaxants and Butrans for signs of respiratory depression that may be greater than otherwise expected and decrease the dosage of
Butrans and/or the muscle relaxant as necessary.

Diuretics

Clinical Impact:
Opioids can reduce the efficacy of diuretics by inducing the release of antidiuretic hormone.

Intervention:
Monitor patients for signs of diminished diuresis and/or effects on blood pressure and increase the dosage of the diuretic as needed.

Anticholinergic Drugs

Clinical Impact:
The concomitant use of opioid analgesics, including buprenorphine, and anticholinergic drugs may increase the risk of urinary retention and/or severe constipation, which may lead to paralytic ileus.

Is Butrans safe to use while pregnant or breastfeeding?

Prolonged use of opioid analgesics during pregnancy may cause neonatal opioid withdrawal syndrome.
Available data with Butrans in pregnant women are insufficient to inform a drug-associated risk for major birth defects and miscarriage.
Because of the potential for serious adverse reactions, including excess sedation and respiratory depression in a breastfed infant, advise patients that breastfeeding is not recommended during treatment with
Butrans.