Ask the PCSS Expert: Fentanyl Patches and Induction?

A physician wrote the PCSS mentor network seeking advice and recommendations on buprenorphine induction for patients on Fentanyl patches. Specifically, the physician wanted to know:

1) Do you switch the patient to a quantity of shorter-acting opiate (eg morphine equivalents) before starting buprenorphine? 

2) Alternatively, do you have the patient go from a 50mcg Fentanyl patch dose, completely remove the patch, wait for opioid withdrawal symptoms, and then attempt buprenorphine induction?

Answer: The physician’s inquiry did not state whether the patient on fentanyl is taking it for pain or has been diagnosed with opioid use disorder. This is important because if the diagnosis is opioid use disorder, switching to a short acting opioid as a “bridge drug,” would violate the DATA 2000 legislation.

According to DATA 2000, only sublingual, and now buccal formulations of buprenorphine or buprenorphine/naloxone combinations, are approved for the treatment of opioid use disorder in a non-opioid treatment program and by prescription. These same products can be used off-label, most commonly for pain treatment. However the reverse is not true: the parenteral formulation of buprenorphine and the transdermal formulation of buprenorphine are FDA-approved only for the treatment of pain, and they are not approved by DATA 2000 for the treatment of opioid use disorder.

If the patient only has pain (and not concomitant opioid addiction), and the goal is the treatment of pain with off-label sublingual buprenorphine, then switching to a short-acting opioid could be done. However, since the half-life of fentanyl is 3-4 hours after patch removal and decreases in serum level occur even later, this switch would not likely result in an “easier” buprenorphine induction. If the question relates to the treatment of chronic pain, and not addiction, then a transdermal buprenorphine patch could be considered.

Linked here is an article which describes a study switching patients from transdermal fentanyl to transdermal buprenorphine and back again. At least in the transdermal formulations, the study did not find precipitated withdrawal. Fentanyl transdermal patches are indicated for severe pain only if the patient is opioid tolerant. The patches have liability for misuse, addiction, and overdose, particularly if cut, and the fentanyl is extracted from the patch matrix. Fentanyl is 100 times more potent than morphine and has high mu receptor affinity.

According to the Fentanyl product insert it takes at least 17 hours after patch removal for a 50% decrease in serum concentrations to be attained; this is a result of a reservoir of fentanyl being maintained in the skin. A buprenorphine sublingual induction should follow the same general guidelines as with any other full opioid agonist: the patient should be in mild to moderate withdrawal as documented using the Clinical Opiate Withdrawal Scale, and then the patient should receive 2 or 4mg as an initial sublingual buprenorphine dose.

If fentanyl is the primary drug misused or involved in the patient’s opioid use disorder, then methadone should be considered if buprenorphine induction fails. Fentanyl has a high potency and methadone may be better as a potent full agonist in comparison with buprenorphine. This might also be a scenario where doses of buprenorphine higher than 16mg may be required for maintenance stabilization. Unfortunately, there is limited evidence or data to guide these decisions.

For more information about the Providers’ Clinical Support System for Medication Assisted Treatment (PCSS-MAT) visit  www.pcssmat.org.

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