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Ask the PCSS Expert: Fentanyl Patches and Induction?

by The PCSS Expert | October 9, 2015

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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.

Providers’ Clinical Support System is a national training and mentoring project funded by the Substance and Mental Health Services Administration led by American Academy of Addiction Psychiatry in partnership with: American Osteopathic Academy of Addiction Medicine, American Psychiatric Association and ASAM. ASAM Magazine is republishing selected questions received by the PCSS mentors. Please note the Mentoring Program and Listserv discussion group and ASAM Magazine are NOT intended to provide clinical consults for specific patient questions and is offered only as a resource for education and overall guidance.

Funding for this initiative was made possible (in part) by Providers’ Clinical Support System for Medication Assisted Treatment (1U79TI024697) from SAMHSA. The views expressed in written conference materials or publications and by speakers and moderators do not necessarily reflect the official policies of the Department of Health and Human Services; nor does mention of trade names, commercial practices, or organizations imply endorsement by the U.S. Government.

19 comments

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  1. jeanne May 12, 2019 - 08:51 AM
    Jeanne i tell my doctor i am in pain and the doctor says the new laws are not in the best interest of patients that need the meds. The pump is a way they give up med throw a pump theyput in under your stomach. Guys trying to get support. For housing and dssi i have to work or be homeless. jeannemaltas7@gmail.com please help.
  2. Carolann Mar 23, 2019 - 01:51 AM
    I’ve been on the fentanyl patch for chronic pain for approximately 8 years. I was up to         75mcg/h. I have weened myself down to half a 12mcg/h patch (i cut the patch in half). I alsochange the patch every 4-5 days. The next step is the cut the 12mcg/h into quarters, if that doesn’t work, because the 1/4 patch won’t stay on, then I’m going cold turkey. I’ve been on  the patch too long, its not working nearly as good as it used to. My pain isn’t much different now, then when i was on the 75 mcg/h. This last step is scary but I’m so done with the         fentanyl.
  3. richard dercks Mar 09, 2019 - 05:19 PM
    I have the same problem. I have been on fentanyl 225 mgr for 18 years. I had a accident and tour a lot of nerves going down to my lower extremes. I am at 100mgr and hit a wall.They put me on a trial using wires going into the spinal canal. Started last wednesday its to early to tell weather its going to help. It definitely is helping, but only time will tell as I am going down to lower levels on fentanyl. The doctors name is Atit Shah, out of sheboygan , Wi. 920-901-7246. My next problem is that as I'm going down in lower levels is when I get up from laying down I get dizzy and out of breath, I have passed out twice and got lucky when I fell backwards and just missed a glass end table by 1''. If anybody has experienced the same problem let me know. rick
  4. Ramona Feb 20, 2019 - 05:43 PM

    yes i agree i am on 100 fentaynol patch beenon it for 7 years for chronic  pancreatitis  Andknow i have anew Dr and he told me that he is lowering my patch to 75 and then he said after the next month down to 50 until im off it completely i have pain from chronic  pancreatitis so bad that i was in the hospital 2-3 times a week until i was giving the patch i told the Dr that and he said well im sorry i dont think you need it and thats what im gonna do i have kaiser permenete so i can choise anotherDr but he is going to put whatever he wants in my file and i told him that when i choose snother Dr they are gonna see all the stuff ypurare saying to me in my file so when they read it they are gonna judge me off of what you say he said well you dont seem like your in pain now by the way your talking to me i was so mad i told him well you dont know my pain do you i asked him do you have xhronic pain ? No you dont so please dont tell me what you think you know a out me im so scared that when i see another Dr they are gonna tell me the same thing i will be in pain and with drawlls i dont know what to do ? 

  5. Thomas george warner Feb 12, 2019 - 06:22 PM
    You should never taper off 75mcg fentanyl patches by dropping to 50 mcg. You can cut them so you can talper off every 3 days by about10mcg at a time. You can also have your doctor orescribe the new FDA approved lucemyra which will take care of the withdrawel
  6. JoAnne Jan 07, 2019 - 05:32 PM
    I was just told today that my Dr won't be able to continue to write my scripts for Fentanyl patches. I was involved in an accident with a semi and have been on pain meds for 6+ years. I take my meds as prescribed abd have wanted to get off I'm scared. Now I have to begin suboxone to get off i Pray they see me and help im not an addict I just want to do this safely abd close this chapter of my life. 
  7. bjr Dec 05, 2018 - 02:06 PM

    I have MS. I have been on Fentanyl 50 patch for over 10 years. After a long struggle and being turned away by many so called pain doctors, My last hope was a pain clinic that has a wonderful holistic doctor. I still have pain on the Fentanyl and have asked to try to taper down to get my body's narcotic receptors more sensitive so I can try something different or at least a lower dose. I am doing a lot of research. My doctor, pharmacist, mental health counselor, insurance co. are all on board for a slow taper. I am scared because I went cold turkey off amphetamines a couple of years ago and wanted to die, the withdrawal symptoms were horrible.I think the frontal seizures were the worst. Ended up calling 911.  I told my doctor that I don't ever want to go back there again. He is great and explains everything, he listens to me, and he tries alternative methods.

    I am not an addict. I do not want to be treated like one.  I take my medication as prescribed. I have a physical tolerance. I don't need to go into "treatment'. I just want to try to have better pain control with something other than fentanyl. 

    Pain medicine is a joke. When my neurologist who took care of all my medications retired, I had to find a pain specialist. I spent months going from doctor to doctor just to be told that they wouldn't see me. They didn't see Chronic pain patients. Didn't see people with MS. Only did epidurals or pain pumps. I don't know what I would do without my current pain doc. I guess it shows that if you keep looking, you might find one of the true Pain clinics out there. But then would you be labeled ""doctor shopping"?

  8. Joe Armstrong Nov 18, 2018 - 04:08 PM
    I believe a doctor should be able to determine what is best for the patient. I think all the illegal drugs coming across our borders need to be dealt with. But leave the doctor to doing their job. I do like the fact that a addict can find treatment. However if a person in chronic pain that is on fentanyl needs or wants off the patch they are limited on what to do. I had a car accident, later I had 3 back surgeries that caused me chronic pain. After years of being on fentanyl 75 I started developing pain in my stomach that put me in the ER many times. They found my gallbladder was not working right so out it came. 2 weeks after surgery the burning inside started. I was told I have narcotic gut syndrome. I never heard of it. My wife is a nurse,  she never heard of it. Look it up. About 6 percent of us on opioids will develop it. It is brutal.  You would think it would be easy to get help but it isn't.  A detox seems to be the only answer. I would have to be diagnosed as having a mental addiction to get help , best I can figure.  All hospitals should be able to help when a bad side effects comes up on  those in chronic pain medication.  I have no Idea of how much pain I will be in if I stop the fentanyl ,but I can't eat without severe pain in my stomach. If you can't eat you die. I know a slow taper will likely be a very painful ordeal. With the current government putting the fear of god in doctors,  I don't know how my doctor is going to react to my diagnosis from gastric PA. I live in Virginia.  Anyone reading this know where I can turn to please leave a comment.  I am in bad shape and afraid. 
  9. dave Oct 03, 2018 - 08:29 PM
    Yes I just love the comment above from the MD. "The patient will do fine." Not to sound mean but I'd love to see some of thee dr's try it who seem to think patients are overdramatizing the COWS and see how their mind would end up. SLow titration? This is why people are killing themselves, not all of them are "weak."
  10. Jonathan Sep 24, 2018 - 02:39 PM

    Is it a good idea to switch an intractable pain patients meds around every so often! For example Fentanyl patch to a Buprenorphine patch! Oxycodone to hydromorphone!  My wife has been ill for 25 years and she seems to hit a wall with pain control for a period of time now and then! I thought it might help her to try to flip/flop meds, but her pain doctor does not agree!   Any ideas would be welcomed!

     

    Thank you

     
  11. MARK Aug 07, 2018 - 11:02 PM
    I ALSO BELIEVE IN WHAT Y'ALL ARE SAYING . IN 2000 I WAS IN AN ACCIDENT AND ALMOST DIED WITH ALL I HAD , BACK BROKE IN 3 PLCES NECK BROKE IN 3 - 5,6,7 IN MY NECK HAVE ALL SUROUNDING PROBLEMS AS DOES MY BACK.  AND MY RIGHT SHOULDER BEING BLOWN OUT MY BACK FROM THAT ARM HOLDING THE STERING WHEEL ALL IS NASTY PAIN. I WAS TOLD I WOULDNT WORK AGAIN BUT I TRIED TO PUSH IT. MADE THINGS WORSE , IF IT COULD. BUT I HAD TO GO FOR TOTAL DIS ABILTY AND IT TOOK A FEW YEARS TO GET IN FRONT OF THE JUDGE AND THE EXPERTS TO COMFERM THAT I WAS TOTAOLY DISABLED AND TO COLLECT MY CHECK EACH MONTH. I WAS PUT ON  VICADIN AND 100 FENT. IT DIDNT SOLVE MY PROBLEMS BUT MADE ME ABLE TO TOLLERATE WALKING THE BOARD WALK AND PARKS FOR EXCERCISE AND TO GET OUT OF BED. STILL HAVE TROUBLES , BUT I CAN AT LEAST TRY THINGS. NOW IVE BEEN DROPPED TO A 50 FENT AND ITS A JOKE. I TELL MY DOCTOR ANR HE WINES ABOUT LOSING HIS LICENCE. CRONIC PAIN IS WHY IM SUPPOSED TO GET TREATED , NOT TOLD I MY HAVE TO GET DROPPED SOME MORE.
  12. Marie Jul 25, 2018 - 11:38 PM

    Unless you know chronic pain and     how it can literally take your entire   life away and make  you just want to die, then you should have no say in  regards to how and when doctors     should treat their patients with opiodmedications in the treatment of the numerous horribly painful conditions with opiod medications.            

    mariewaki@icloud.com                   Marie W.   BSN, RN                                    Please feel free to email me in          regards to this disgraceful issue for     or support, or if you feel ready to     take action.  We as chronic pain       Patients need to unite and take        action now.

     

     

     

     

     

     

     

       

  13. NoMORE Jul 14, 2018 - 07:44 AM

    I feel so awful for you.. I hate Fent..! I had a slip & fall. I have 4 compression fractures in vertbrae, just had my c6c7 fused together & got aporoved thus week to repair the full tearin my R rotator cuff.

    i know oppiates, i never needed it. As soon i was sent for tests, started me on 25mcgs,     150 10/325 Norcos.

    Next month:50mcgs

    Next month: 75mcgs

    Next month: (take a guess) 100mcgs

    im scared... (im 42)

  14. Lindsay Duke Jun 16, 2018 - 03:11 AM
    This treatment of legitimate chronic diseases and pain patients in many ways violates our Constitution not to mention the Hippocratic Oath the doctor swear to hold their position, and Many times criminal ... through paient abandonment , dismissals of ' continual care patients' with serious disease / genetic disorders etc.  Would it be ethical to tell a hospice patient to 'stop ' pain management  or to be weaned off their medicine to die in unrelenting pain? Of course not, But that is essentially what is happening to the continual care chronic pain community,  for our illnesses / diseases /genetic disorders are essentially with us to our deaths, and will never cease till such... THERE IS ONLY ONE WAY TO FIGHT THIS EVERYONE; IN COURT AND ON THE WORLD STAGE THOUGH OUR VOICES! We must make noise, inform the media, the medical broads Everytime a doctor/ practitioner/ clinic is operating  unethically, and Yes, the courts... If we are being harmed we need to have presidents and verdicts through law suits and claims that support our constitutional rights for life and Liberty, and enforce government to stay out of our medical care! We have to do this for ourselves and each other... For doctors sadly have made it clear they will not fight for us nor up hold the Oaths they took...
  15. Texas Pain Patient Apr 22, 2018 - 10:03 AM
    The biggest problem with titrating patients off opioid medications is that some actually need them. I need nerve ablations in my cervical and lumbar regions due to a couple of car accidents where people behind me couldn't be bothered to pay attention. My sciatic nerve was damaged and bones in my neck were broken. As a result of the most recent accident, I am unable to work at the 6-figure job I used to have and now get Social Security, for however long that will last, at less than a third of my previous income. And for this, I am told by my insurance company and the government what kind of care I can have and when! For example, the ablations I mentioned are limited to every 6 months. Why? It's cost effective is my guess. I am a fast healer unfortunately, and I start having pain again in four. Too bad. No meds for me, because my metabolism runs so high OTC meds don't work and I'm allergic to almost everything any way. Thanks for the Irish heritage, mom and dad.
  16. Lisa Via Mar 21, 2018 - 05:59 PM

    I agree with Liz and Jae. I wear a 75mcg fentanyl patch and Dr is "weaning" me off of the medication that gave me a better quality of life as a chronic pain patient! The government has NO CLUE about chronic pain nor do they care. I went from a 100mcg patch to 75mcg and had HORRIBLE withdrawal for 3 weeks. He then moved me to 50 mcg and I got deathly ill. He finally moved me back up to 75mcg but now I live in fear of having to come down again.

    Someone from the chronic pain society,etc nerds to step up NOW and stop this insanity of treating pain patients like drug addicts! I could really use some support. PLEASE feel free to email me at lisavia@gmail.com .

     

     

     

     

     

     

  17. Liz Feb 24, 2018 - 04:09 AM

    JAE

    I AGREE WHOLE HEARTEDLY. IVE RECENTLY BEEN CUT WAY BACK ON MY FENTENYL PATCHES AND AS A RESULT IM HAVING SEIZURES, CHILLS, DEBILITATING PAIN, NAUSEA AND CANT SLEEP FOR LEGS JERKING OR EAT. I CALLED MY DOC AND HE WONT HELP ME. I DONT ABUSE MY MEDS BUT I DO NEED THEM OR THIS HAPPENS. ITS NOT RIGHT TO FAULT EVERYONE FOR OTHERS ADDICTION. AND YOUR RIGHT CAUSE I FEEL LIKE IM DYING AND PEOPLE WHO GET DESPERATE DO THINGS TBEY NORMALLY WOULDN'T DO

  18. Jae Feb 07, 2018 - 01:30 AM

    This whole "opioid" epidemic, really is a heroin epidemic and is KILLING patients who have debilitating pain! I think this is their goal, to kill off all the "burdens" of society.  If they take pain meds from people in severe pain, they have three choices: Suffer needlessly, crying out in pain until they die of heart attacks from pain, commit suicide, or worse, go to the streets for pain relief so they can have a life again. 

    I'm not talking about "junkies," people whom I believe DO have a disease, I'm referring to patients with chronic pain conditions who are being denied the quality of life they had with pain control and who are now having to stay in bed all day and see no one.

    They WERE starting to have lives again until the DEA, Congress and the so-called AMA (who I don't think they are who they claim to be, probably all lobbyists!) decided that pain patients are "junkies" too, even though they don't abuse their medications, and are kicking them off meds with NO REASON!

    This is shameful and cruel!

    Patient in agony

     

     

  19. C Marlo Baird, MD Oct 14, 2015 - 10:13 PM

    Only number two makes sense, with slow titration monitored by vitals and COWS  overs the first 36 hours, the client will do fine.

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