Bear with the long post, it should be worth it. I have been prescribed Butrans 20mcg patches for nearly 2 years for moderately severe chronic back pain. I have researched them Extensively and use them primarily for pain relief but also to keep my breakthrough pain dosage of oxycodone lower. Butrans is definitely more effective when combined with other medications like Lyrica, Robaxin, NSAIDs, traditional full agonist opiates and there are some potentiators in my experience- I would always recommend Butrans in combination with other drugs for chronic pain and your doctor probably should too. Personally, around the clock it does wonders for turning down the volume of my pain a few points, perhaps from 6/10 to a 3 or 4. For people looking for a buzz, this won't be worth your time. It certainly takes 2-3 days for sufficient relief from first initiating treatment with Butrans. A 15 or 20mcg patch will help immensely for withdrawal from therapeutic doses of something like oxycodone or hydrocodone, but don't expect heavy / illicit opiate users to be impressed because the dose simply isn't high enough. However, it's better than nothing! A primary reason heavy users won't be impressed is the slow onset of action. Addiction is strongly connected to rapid onset so Suboxone will be needed for people taking high doses, perhaps if they take more than 100mg Oral Morphine Equivalent daily. If you don't have a solid understanding of opioid conversion to the standardized OME, do some research. It took quite a bit of research to find Butrans conversion values but a 20mcg patch comes out to 40 - 48mg of oral morphine daily. In comparison, 30mg oral oxycodone over 24 hours equals 45mg OME with a conversion factor of 1.5 : 1
A few key points:
-The manufacturer recommends changing the patch every 7 days and is supplied in boxes of 4. However, I change mine every 6 days because the drug is no longer being absorbed after day 5. The long half-life of 50 odd hours accounts for the extra 2 days, so you still have some active drug but you can expect to notice it wearing off by day 7. However, some people do fine with 7 day dosing so at least give this a try. If nothing else it gives your body a slight taper each week and will help keep the drug effective with less tolerance build up over time. I needed reliable and consistent pain reduction and 6 days has worked great for 2 years straight. I have zero desire to change the patch after just 5 days but the first 12-48 hours of a new patch are certainly much stronger.
-Once you are using the patch on a regular basis and have steady state plasma levels of buprenorphine, breakthrough opiates won't work quite as well. I would say they feel half as strong and wear off faster. You probably know Bupe has an extremely high binding affinity for the mu-receptors and only the strong opiates are able to compete and bind. However, Butrans is not a very high dose of Bupe so roughly only about 50% of the mu-receptors will be occupied by it. My pain was so much better when I started Butrans but physical activity would still cause the pain to flare up so I take oxycodone 10mg 3x/day. It was such a relief to finally get that relaxed feeling in my legs at the end of the day when I lied down for a while, but IR oxycodone alone wears off too quickly to be reliable. The combination is effective even if some pharmacists will tell you oxycodone won't work if you're taking it. They haven't researched the graphs and data like I have and certainly haven't lived the experience.
-Initiating Butrans when you're already tolerant to oxy can potentially cause precipitated withdrawal, but not super severely. Most likely nothing like starting suboxone too early, but this is where the warning comes from. It may be necessary to lower the dose by some amount before the switch. This question will be hard to find a direct answer to and varies significantly between patients. If you feel withdrawal setting in, this should happen slowly and since plenty of receptors are still open you could take a percocet and probably feel fine.
-The patches stick quite well but TEGADERM covers are necessary to keep them from peeling away or sliding around / bunching up. The patch alone will come off while swimming and you should cover them with Tegaderm waterproof film even in the shower. These covers aren't perfect but they help a lot. If you expose the patch to heat, like hot water, you won't notice immediate effects but the patch will wear off earlier at the end of the week because heat causes the delivery speed to increase by ~ 50%. The instructions say not to, but clean the skin with alcohol around the patch perimeter where the adhesive will stick and shave if you're hairy. Just don't break the skin or dry it out. NEVER cut the center of the patch where the medicine is, but if the patch wrinkles on you it helps to snip the adhesive border a little to help it flex and lay flush on curved skin. This all takes trial and error. Keep the patches dry or itchy & somewhat painful blisters will develop. This happens even from sweat, it's a tradeoff and completely worth it. The patches never stuck well on my chest or back. I use ribs and triceps, alternating and moving the exact repeated location by a few inches every time.
-Tegaderm patches are stupid expensive at the pharmacy. $20 for 4 at the store. Buy them ONLINE, medical refill packs of 50# cost $25 and they are Identical. Get the size 4" x 4 - 3/4" Item # 1626W
Now, to answer your primary question. Butrans for withdrawal relief if you're tolerant to 60mg oxy ER daily...
First - you must start the patch a couple days before running out of the other medicine and be nice to your body, save enough oxy to taper for several days and allow the transition to work. 60mg oxy = 90mg oral Morphine Eq. Which means a 20mcg patch will be equivalent to a 50% dose reduction of opioid. My medicine was stolen once and I used the patch to ease withdrawal symptoms, it worked very well. You will feel somewhat exhausted and depressed with some cravings but I wouldn't expect nausea or strong anxiety. Your bowels will work better but not diarrhea. Now, these symptoms are notoriously subjective so keep that in mind. I would also recommend quality kratom which does work for me in combination with Butrans. The two of these should keep you going just fine in the absence of a full agonist opiate but remember you will pay for it one way or another if you take too much of your medicine and run out early. The butrans should keep you sane and out of the ER needing relief.
There is something dangerous about your idea! The highest dosage allowed in America for transdermal buprenorphine is 20mcg/hour because studies have shown higher doses can cause dangerous heart problems - specifically QTc wave interval prolongation. This condition is rare but potentially deadly so I have never taken more than 20mcg. However, TransTec is used in Europe, same thing as Butrans but comes in higher doses up to 70mcg/hour. Not sure why very high doses of suboxone are tolerated while transdermal delivery can cause this problem. Therefore, don't use multiple patches and doctors shouldn't be recommending doing so. Most doctors are very poorly educated on Butrans. I really don't think you would need 2 patches to ease the withdrawal anyway! I certainly didn't.
Back to the notion of combining Butrans with other meds for the best results. This is where things get interesting. Lyrica really kicks it in and will subdue peripheral or radiating pain very well at doses of 300-600mg / day. Normal doses of DXM, especially the 12 hour extended release cough syrup, make Butrans much more sedating and effective for me. To the point that I was using it on a regular basis and sleeping longer than I should. Lastly, Tagamet (cimetidine) is a common hepatic enzyme potentiator of many drugs. While online resources don't typically list cimetidine as interfering with blood levels of buprenorphine, I am positive that 400mg once a day will make a big difference! I can't comment on the safety of these combinations and I wouldn't take them on a regular basis, do your own research. Cimetidine can also potentiate Kratom quite a lot! If you combine them take half the regular dose of Kratom to test.
Finally, buprenorphine is a wonder drug for people trying to stay healthy. Tolerance develops quite slowly and it does not destroy receptors in comparison to full agonists. Some research actually suggests Bupe can heal and increase receptor count, leading to the body naturally fighting off pain more effectively. Without insurance these patches cost $180 a piece, so check if your insurance company covers them on the prescription formulary guide. If the doctor offered me unlimited oxy if I gave up the patches I would say NO, and find a new doctor.
Coming off of Butrans needs to be tapered just as much as anything else. The withdrawal from cold turkey was anxious and quite uncomfortable and I only went a few days too long. However, it's a much safer long term medication than percocet and the strong cravings that make you gobble up the oxy simply won't be a factor. You will feel healthier after the transition. This guide is not just for the original question but anyone considering Butrans. I HIGHLY recommend it. The 5mcg/hour patch is quite weak but your doctor may want to start new patients at this dose and titrate up every week. I would certainly try 20mcg Butrans before jumping on suboxone because the dose will likely be too high and much harder to quit. Good Luck.
