Changing from Bupromorphine sublingual tablets to patches

[Palamino]

Hi I've been on bupromorphine 400 micrograms 2 mornin and 2 at nite although I used to only do 1 day and 1 nite. Since having a knee replacement 3 months ago it has got worse again . I know inflammation can make it worse but I also have pain in my outer thigh on same lef as knee replacement. So that whole leg is driving me nuts at night the bupromorphine doesn't seem to be working at the moment . I saw doctor last week and said he would put me on patches I think he said 5 to 10 micrograms I think . He thinks that will help with the pain in my thigh amd my legs . I live in hope !! Not got the patches yet but am dreading stopping my tablets . Should I do it slowly or just go straight to patch as they are the same drug ?? I also mentioned the Mayo algorithm and he said in UK they go by NICE guidelines. I explained that was outdated and didn't work. He only gave me bupromorphine because I had looked I to it on here and u all helped me so I had the information at hand . But he said there's not enough proof that it works !!! I was like surley the amount of people getting help from it proves it works !! Otherwise I would be in seeing him all the time like I used to be in tears. But no he wasn't havi g it and tried to usher me out . Its crazy how they don't listen to actual sufferers it drives me mad . So I just wanted to know how to go about transferring over to patch please

[LotteM]

You can do a straight switch. Put it on in the morning and it should work by night. If not yet, add half (or even quarter) pill. Pay attention to where you put the patch, there are instructions in the leaflet. And be aware that warmth (when too much) may increase the uptake rate from the patch, which may effect the duration of the effectiveness of the patch. For me it usually works 7d, although I sometimes need an extra pill the 7th night. But several people have reported here that the patch took longer to start working and did last only about 4-5 days.

In my case, I only took pills before bed and experienced withdrawal in the morning. The patch got far better rid of the daytime withdrawal symptoms at a much lower dose then when I took 1-2 extra tablets during the day.

Has the surgeon of your knee replacement looked into why you are having (muscle) pain in the operated leg? Maybe you need fysiotherapy rather than just upping the painkiller. As you also say the buprenorphine is not yet covering your pain, you may be on a dangerous road to increasing doses of painkillers without addressing the dose. This no longer seems about covering the RLS. Red flag? Please be prudent and get better soon and back to only your evening dose pills for the RLS.

[Palamino in reply to LotteM]

Hi thank you . The pain is probably because over the last 10 urs I have had k ee problems in my other knee the right one . I had a partial knee replacement in 2017 which turned out to be loose not enough cement so in 2019 I had a full replacement in the same knee . Because for such a long time I've been limping and putting extra pressure on the left leg that has finally given up. So had another knee op in left knee . It's been a long road of pain and I've built up a resistance to strong pain killers . So do u think I will still need pills in the evening as well as the patch ? I am also on the hot side and have nite sweats so not sure how the patch will work that . Also last time I had patches I was allergic to the glue and had red square marks all over me lol . I. Am doing physio for my knee but my hip is hindering that and now I have to do physio for my thigh !! Joys of getting old lol

[LotteM in reply to Palamino]

I don’t kniw whether you need additional pills to the patch. But a switch of medicines always required some finding out and adjustments to get to the lowest effective dose. In that situation adding (half a pill) may help, as the patch is a slower and also 7d medicine. And it seems that in your case the buprenorphine is more for the pain than for the RLS, which makes it more complicated.

[Palamino in reply to LotteM]

I've been on it 4 yrs for rls I've had all the normal drugs they give u . It was working fine up until my operation . It can be used for pain aswell though cant it ?

[LotteM in reply to Palamino]

I think the buprenorphine can be used for pain. But as far as I know it is far from among the first or even second choices for pain. And it does interfere with the effectiveness of other opioids, which makes it complicated. (I am not a medical doctor or pharmacist)

[Palamino in reply to LotteM]

I understand ur not a professional but u suffer with Rls and most people get better more up to date info on here than they do from some doctors . So i appriciate any help I can get .I have read itvcan be used in larger doses for pain but he s not really giving me a large dose . I will try and see what happens and let u know. The last 2 nites I've rubbed cbd oil made by a friend into my leg and have been ok ....who know s if its that but we try anything we can when we're suffering . Thank u for ur help

[707twitcher in reply to LotteM]

LotteM,

I just noticed your comment about having withdrawal issues when taking buprenorphine pills (after I told Palamino that you don't have to worry about mini-withdrawals with buprenorphine because of the long half-life). That's the first I've heard of it. The discussion about buprenorphine's half-life (24+ hours) vs. effective life (10-12 hours) has always confused me. What were your withdrawal symptoms like? I gather you're sure it was withdrawal, not just buprenorphine side effects?

[LotteM in reply to 707twitcher]

I understand that the elimination of buprenorphine (and methadon too) show large inter individuality. With buprenorphine, the first breakdown substance is also effective, which complicates things.

I also had mini-withdrawal on oxycontin. It felt like a general feeling of being unwell, a faint nausea-like feeling, uneasiness, overall-body slight restlessness, and some muscle soreness. A bit like when a flu is developing. Both the pharmacist and an addition doctor confirmed it sounded very much like withdrawal symptoms.

And it was also definitely withdrawal, because it developed in the morning after I had taken one buprenorphine 0.2mg sublingual pill the previous evening around 10-11pm. And it disappeared quickly if I took another pill during the day.

[707twitcher]

If you are taking 1.6 mg of sublingual buprenorphine, you are likely to need the 20 mcg patch. The attached chart shows dose equivalency for various opioids. The buprenorphine patch description is confusing, but footnote 4 clears it up a bit. Bottom line is divide the sublingual dosage by 60 to get patch dosage. That would be 27 in your case. Everyone is a bit different, so the conversion factor of 60 isn’t necessarily gospel. But it’s at least a reasonable starting point.

communitycarenc.org/sites/d...

I’d strongly recommend keeping plenty of sublinguals handy, as they are fast acting (30-60 minutes) and you can supplement the patch as needed. Sounds like the patch is just an experiment anyway. So trying it, even in a 5 or 10 mcg dose, could at least show you if it helps at all. Just plan on backfilling with the sublinguals as needed.

[Palamino in reply to 707twitcher]

Hi its micrograms I'm taking not milligrams. I was fine on the pills until my knee op and I've been fine when my other knee was operated on twice but this time it seems to have gone mad. The pain in my thigh is apparently the soft tissue that runs from the top of your outer thigh to your knee . So he thinks by upping dose and using patch will help both. I'm quite worried about changing as we all know wot Rls is like

[707twitcher]

I understand. Four pills @ 400 mcg = 1600 mcg = 1.6 mg.

As far as switching, I switch between sublinguals and patch occasionally. No issues other than allowing for the ramp up period with the patch.

Definitely tell the doctor you want to have enough sublingual available to backfill the patch as needed. You can cut your 400mcg pills in half and take one every 45 minutes or so until you get the necessary relief. You’ll need it, especially if you get a 5 or 10 mcg patch. With any switch, give it a few days to settle before concluding what the right dose is for you.

[Palamino in reply to 707twitcher]

Ah thanks I read it as 16 not 1.6 lol sorry. So if I half the pills when do I start taking tablet s . Would it be just after putting patch on ? As I have other bile binding pills I take and I have to have 4 hours before and after clear of taking any other pills . Would a higher dose patch be better. That's if Doctor will

[707twitcher in reply to Palamino]

It would help me to first know why you're taking buprenorphine twice a day. Have you always done it that way? Do you get RLS symptoms during the day if you don't? Buprenorphine has a very long half-life (generally 24-30+ hours), so there is no issue with mini-withdrawal symptoms like what would happen with other opioids. And one dose a day (usually in the evening) handles RLS for most people. Do you have any unpleasant side effects from it?

[707twitcher]

another thought - I haven’t heard of anyone taking buprenorphine twice a day as you are. Do you get RLS symptoms during the day if you don’t? If not, you might be better taking it only in the evening ? Then you could try increasing dosage to 3 pills in the evening to see if that makes a difference.

I assume your doctor doesn’t think it’s a nerve issue resulting from the surgery? I wonder if trying some gabapentin would help? That might address a couple issues…

[707twitcher]

last one, I promise 😂.

Maybe just keep your pill routine the same, and add a 5 mcg patch to it and see what happens. Maybe that is what your doctor has in mind anyway? Depending on results of that, you could explore other options like reducing your other doses, getting a higher dose patch, etc.

[Palamino in reply to 707twitcher]

Hi my doctor prescribed it like that I used to do 1 morn and one eve then more recently 2 in eve but since operation its been 2 morn 2 eve. But today I've just found a u tube video from the mayo clinic saying unless u get it in morn u shouldn't take it . I don't think my doctor really knows what he s doing . I have been on here ages ago when I first found d out from Karema I think about bupromorphine. I've always took it that way and been ok . I worked nites so I think having it in morn helped as that's when I slept . It could be nerve damage as knee replacement s quite a brutal surgery I'm stil in alot of pain . I can take strong painkillers and they don't touch me .

[707twitcher]

If you aren't experiencing any bad side effects from the buprenorphine, then you probably should continue with your normal regime at least until your current pain subsides. Later you can explore cutting back on the burenorphine to once a day (with a slow transition).

My suggestion would be to add a 5mcg patch to the 4 pills you are taking to see if there is any noticeable improvement. In theory, you could drop one pill to offset having a 5mcg patch (or 1 1/2 pills for a 10mcg patch). But take it one step at a time.

I think you would get withdrawal symptoms if you cut back the buprenorphine quickly. And swapping your four 400mcg pills for a 5 or 10mcg patch would be a serious cutback.

A lot of people here take buprenorphine and gabapentin. Have you tried it before? Has your doctor mentioned it? It is frequently used for nerve pain (in addition to aiding sleep, RLS, general pain, etc.).

[Palamino in reply to 707twitcher]

That sounds like an idea with the patch and 3 pills then see how that helps and cut back from there . It's very complicated. I've had gabapenten before can't remember why I came off it prob didn't help and I had it in hospital recently didn't touch the pain . It took a few days for morphiene to work as they would give it me for a day and a half and they knew I was in pain . The other 2 operation s I had morphiene straight away and it worked immediately. I ll wait til he gives me the patches luckily I have a back log of bupromorphine to rely on if he won't prescribe any thanks alot for urbhelp