Buprenorphine transition from patch to tablets

[RiversW]

Hey Everyone

With the help of a 20 mg 7 day Buprenorphine patch, I have been free of any dopamine agonist for almost 3 months. But as we all know, the patch does not last 7 days, 5 if you are lucky. Consequently, I change it every 5 days and have had pretty good results. Initially, I would have moderate RLS symptoms after 3 days, slightly more serious ones on the 4th day and on the 5th day the action really started. This is the important part. Last night was the 5th night in the cycle and I have had no symptoms on the 3rd, 4th or 5th night. Could this be an indication that I am moving away from the severe effects of augmentation and withdrawal toward my more baseline symptoms of RLS? Can I start thinking about experimenting with reducing my dose of Buprenorphine?

In Brasil, Buprenorphine is only available in a patch and in the amounts of 5mg, 10mg or 20mg. If I switch to the tablet, I would have more flexibility in titrating the dose, right? More flexibility in dosing would allow me to find the smallest amount of Buprenorphine needed to cover my RLS symptoms and to possibly transition away from Buprenorphine entirely. Next week, I am headed to the states and will ask my neurologist to prescribe Buprenorphine tablets. To start this process, I need to be able to convert the equivalent dose of a 7 day 20 mg patch to a Buprenorphine tablet taken daily. Can someone help me with this calculation?

After 30 years of RLS, Buprenorphine has given me my life back and I will continue to use it if needed, but I would prefer to use pregabalin or gabapentin. Easier to obtain and much less hassle from doctors, hospitals and pharmacies. Any ideas?

As always, thanks! Rivers

[SueJohnson]

On your pregabalin/gabapentin comment. I remember you had some side effects on pregabalin you didn't like. Did you ever try gabapentin?

[RiversW in reply to SueJohnson]

Your are right, thanks for remembering. However, the side effects from pregabalin, specifically poor equilibrium, have passed. And believe me, on the bumpy sidewalks of São Paulo, one cannot afford to not have good balance. I have seen people of all ages go down. Presently, I am taking 150mg of pregabalin at 8pm without any issues. It took awhile, 4 or 5 months, but I am ok now.

About 4 years ago I saw a neurologist in LA whose primary concern was trying to get me off codeine. If I remember correctly, she had me on 1800 mg of gabapentin from the get go. My brain ran for cover. I was truly messed up. She was the same doctor who told me that if I had restlessness in my arms, it wasn't RLS. I know now I was augmenting. I saw her once and stopped the gabapentin.

On a side note, I am forever amazed that you and Jools are able to keep up so diligently with the post on this site. You have my undying admiration and respect.

Thank you Sue

[RiversW in reply to SueJohnson]

Sue I asked Jools this question and want to run it by you as well.

Do you think I could start experimenting with a smaller dose patch or should I stay the course a bit longer. Could I perhaps change the patch every 6 days instead of 5? Or should I wait to be certain the symptoms don't return on the 5th day again? Thanks

[SueJohnson in reply to RiversW]

Joolsg or others are much more knowledgeable about this than I am.

[RiversW in reply to SueJohnson]

Ok, thanks so much. R

[LotteM in reply to RiversW]

It is indeed difficult to tinker with the dosing with the 7d patch. I am on a patch as well, 5mcg/h only, which works for me.

Firstly, I wouldn’t mess with the dose when you are away from home. If your current 20mcg/h works well keep at it and keep replacing at day 5. Note: I keep the old patch on one day longer, hence I always have two patches on the first night on the new patch. I find it helps to have a smoother change over.

Secondly, I would experimenting when back home and rested enough. Then I would change the patch one day later and be prepared to have a restless night. I have compression socks that help with mild breakthrough symptoms. And there is of course the good old stretching and walking. You may even consider to buy a therapulse if you can afford it.

If the patch continues to run out after day 5, consider cutting a small part h of the (active) patch of the patch. You can see the thinner edges with glue only. As always when reducing, go slow. Eg aim for 5% off. I assume you can do the math. If not, drop me a note.

Finally, re the conversion between tablets and patch, I can only say that for me a 0.2mg sublingual tablet worked as does the 5mcg/h patch. For you this would translate in 0.8mg sublingual tablet. Ad the tablets work quite fast, you can start on a slightly lower dose, wait 40-60min and add another (half) tablet to find you lowest effective dose. For this you need 0.2mg or 0.4mg tablets, but they may not be available to you. But you’ll find a way.

I hope this is helpful.

[Joolsg]

A straight forward calculation doesn't necessarily equate to the correct pill dose as the patch works so differently to pills.20mcg x 24 equates to 480mcg over 24 hours. The straight switch would be 0.5mg.

However, pills give out most of the active ingredient over the first 10 hours, so you would be getting more of the active ingredient at that time.

You may have to experiment.

Sadly, the USA only supplies 2mg pills, so you will need a pill cutter to cut into quarters.

I would have suggested starting at 0.2mg for the first few nights to see how it goes, but, cutting into ⅛ may be difficult.

Many in the USA use the buccal film for this reason. It's easier to cut the film into ⅛.

Good luck and I hope you can find the smallest dose that works well.

[RiversW in reply to Joolsg]

Thank you Jools, I can see now why my neurologist in California said he was not certain how to calculate the difference in doses between the tablet and patch.

[RiversW in reply to Joolsg]

Do you guys think I could start experimenting with a smaller dose or should I stay the course a bit longer. Could I perhaps change the patch every 6 days instead of 5? Or should I wait to be certain the symptoms don't return on the 5th day? Thanks

[Joolsg in reply to RiversW]

I honestly can't offer advice on that. It really is a case of trial and error and experimenting to see what works for you. I've never used the patch personally, so can't give my own experience on it.

[RiversW in reply to Joolsg]

Thanks Jools

[Danni54 in reply to RiversW]

Hi. I thought I would let you know what is happening with me as I'm changing from a 20 mcg Buprenorphine patch to 0.4 mcg Sublingual tablets. The patch was blistering my skin but I, also, had to change it on the 5th day. I am still experimenting and I'm finding I'm exhausted and the first day I had taken 1 in the morning and 1 at night which I found was too much. My prescription was for 1 , 3 times a day but found that far too much. My Dr. rang yesterday and is happy for me to experiment so I am taking ½ a tablet at 3 p.m. , another ½ at 9 p.m. but I wake at 3 a.m. with leg's kicking so , last night another ½ at 3 a.m. ! Sorry not to be more helpful but I'm still finding my way !I have a sensitivity to painkiller's or any tablets (!) so I'm hoping that my body will function better in a week or so. RLS is such a horrendous ' Syndrome ' and I've had such a struggle with our Pain Clinic and Dr.s to be allowed to have Buprenorphine but it does help. If it hadn't been for Jools and Sue and other's, I would be having a nervous breakdown and I came very close. Their help and advice has been amazing and I'm SO grateful.

I truly hope that you find rest from this horrible Syndrome which medic's do not seem interested in....not in Scotland anyway. I asked my Dr. about seeing a Neurologist but they here , apparently prescribe Ropinirole! No thank you! Good luck and take care.

[davchar23]

Dear RiversW

Joolsg & Sue J are much more on the detail than myself but as i have experimented with both buprenorphine patches & tablets i thought i would give you a summary of my experience

My GP used a factor of 60 to convert patch to tablet. i am currently on 400mcg per day and have founf d that 500mcg is too much but even 350 not enough. I was previously on one 10mg patch and like you found they did not last 7 days probably only 5+

These are the points to watch:-

-nausea caused by peaks of buprenorphine can be (not to everyone) a major issue and with me it is

-The tablets are at their peak 6-10hours after use sublingually and that is when nausea trips in and last , WITH ME, until about 12 hours after dose.

-Whilst not "peaking" the problem with the patch is not only knowing how long it is effective for but also it does vary (with showering ,temperature etc.)

Because of the nausea which I have not been able to reduce i am thinking about going back to patches but which ever way you go ie patch to tablet ot tablet to patch be careful as the buprenorphine half life (re twitcher 707 work on this forum) is still under review but thought to be 30-36 hours. As as result it is possibly to overload your system with too much drug and then suffer withdrawals etc.

Hope this helps

Davchar

[RiversW in reply to davchar23]

Hey Davchar,

Thanks so much for the patch to tablet conversion information. As I just wrote to Twitcher, I am not ready to move from the patch to the tablet entirely. As things are, I am doing so well. Unlike you, the side effects I am experiencing from Buprenorphine are very manageable. However, when and if I do start to experiment with extending the life of the patch or going to a lower dose, I would like to have the tablets as backup in case I run into problems.

I am sorry to hear you have not managed to get the nausea under control. It must be discouraging to find relief from RLS but run straight into nausea. Hang in there!

I really hope you can figure out how to get relief soon. Good luck!

[707twitcher]

I have experimented some with patch and sublingual strips. The attached chart shows equivalent doses of various opioids in MMEs - which basically compares them all to morphine. The chart is difficult to understand for the buprenorphine patch, but footnote 4 ultimately leads you to a conversion factor of 60 when comparing patch to sublinguals. In your case, this would say multiply your 20mcg times 60 = 1.2mg. This is more than a straight conversion like Joolsg pointed out of 480 because the patch supposedly absorbs differently. This doesn’t mean 60 is the exact conversion for everyone, but it is a reasonable starting point. It works for me, as I find that a 7.5mcg patch provides the same relief as .4mg of sublingual.

communitycarenc.org/sites/d...

As far as your other question, it sounds like you are reaching a point where the dose could come down some. That also means that you might get 6 days out of your patch instead of 5. I get 6 days on mine. But if you are able to wait until you can get pills, I would wait. It’s always helpful to be able to have the almost immediate relief available (30-60 minutes) if needed. Ultimately, I think the flexibility of the sublinguals clearly makes them preferable. But if the side effects bother you, the patch MIGHT be better because you wind up with less medication in your system because of the absorption differences.

I have just tried tramadol instead of buprenorphine, and that was a bust. The extended release tablets are supposed to last 24 hours, but didn’t last even 12 hours for me. The conversion table would imply that 100mg of tramadol should work for me, but even 200mg wasn’t working well. And I was getting heartburn as a side effect. So I’ll stick with buprenorphine.

Everyone reacts differently, and I think we react differently individually from time to time. I’ve noticed that my symptoms have changed recently. I get more discomfort in my arms and shoulders, not just legs, when I miss a buprenorphine dose.

Good luck!

[RiversW in reply to 707twitcher]

Thank you so much Twitcher for this information and your advice. Indeed, I don't think I am ready to move from the patch to the tablet. As things are, I am doing so well. However, when and if I do start to experiment with extending the life of the patch or going to a lower dose, I would like to have the tablets as backup if I run into problems.

It is so interesting that you have noticed a change in your symptoms. Since I started Buprenorphine, I have as well. On the 5th day, when the effectiveness of the patch wanes, symptoms sometimes show up, but in places where I did not experience them before. When I was going through augmentation, my feet, thighs, arms and even above my right eye would burn. Now if I have burning symptoms, they are right in the middle of both knees. Not nearly as severe as before, but present nonetheless. Everything with RLS is unpredictable and crazy.

Again, thank you. And good luck to you!

[Shumbah]

Yes we are all guinea pigs , but rather that than no Buprenorphine for this vile disease

I was not on a patch prior however if it was me I would use the patch until it’s day where it usually runs out and then take a pin head sublingual of BUP tablet .

You will notice it work very quickly, wait 15 min or more before adding more Bup of needed until you get the desired result .

I would rip and rip your patch off as you take your first dose. Worse case you have spare patches. I was travelling to the USA and in NYC and did a clean switch from oxycodone .

Alternatively Dr Glen Brooks may be of some help

[e-mail]

He responds personally

All the best

.

[RiversW in reply to Shumbah]

Thanks Shumbah

[Kakally]

Hi RiversW

I have completely sorted the patch problem by putting a 5mg patch on my right side on Tuesday and a 5mg patch on my left side on Saturday. So I always have 2 lower dose (I only need 10mg in total) patches on but get a little boost of dose twice a week. It gives me a constant high enough cover of my RLS . I guess you could try that but with 10mg patches… anyway all the best to you 🤗

[RiversW]

Thanks Kakally, it is medication musical chairs isn't it? Take care