Posts Tagged ‘pain’

BuTrans

 

By Trevor Shewfelt, Pharmacist at the Dauphin Clinic Pharmacy 

We now have this and most other articles published in the Parkland Shopper on our Website.  Please visit us at www.dcp.ca

The information in this article is intended as a helpful guide only.  It is not intended to be used as a substitute for professional advice.  If you have any questions about your medications and what is right for you see your doctor, pharmacist or other health care professional. 

There is a new pain patch on the market.  It is called BuTrans.  It contains the narcotic buprenorphine which is new to Canada but has been in other countries like Australia for several years.  The medication buprenorphine in the patch is very potent.  That means the patch only needs to contain a tiny amount of the buprenorphine to be a good pain killer.  The three things that caught my attention, though, were how long the patch lasts, what type of pain it is aimed at, and if it can used early or late in the course of pain treatment.

When I first heard about the BuTrans patch, I assumed it would be very similar to the fentanyl pain patch.  In pharmacy world we call that a “me-too” drug.  One company develops an innovative product and many other companies market products that are very similar, offer no real advantages and just let the other companies say “me-too”.  I could be wrong about BuTrans.  It seems not to be a me-too of the fentanyl patch.  The first difference is duration.  The fentanyl pain patch is designed to release pain medication for 72 hours or 3 days.  BuTrans is different.  The BuTrans patch is designed to release pain medication at a steady rate for 7 days. 

The second big difference between the two is what type of pain they are used for.  Fentanyl pain patches are usually reserved for very severe pain.  Although I have seen fentanyl patches used in all sorts of severe pain from severe arthritis to severe nerve pain, the most common use I see for fentanyl patches is still cancer pain.  Again, BuTrans is different.  The official indication says it is aimed at moderate persistent pain that lasts longer than 6 months.  Notice it doesn’t say severe pain, and it doesn’t mention cancer pain.

So, what kind of pain is BuTrans for?  Two studies I looked at examined BuTrans versus osteoarthritis of the knee and hip and BuTrans versus lower back pain.  These two types of pain would usually be considered not severe enough warrant a fentanyl patch.  The first study was a small trial with 327 patients in it that took people with osteoarthritis of the knee and/or hip and put everyone on BuTrans.  Once they got their pain under control, the patients were randomly split into two groups.  Half the people got a BuTrans patch and half got a placebo patch.  The amount of time it took for the “first pain episode” in the placebo group was 7 days.  The amount of time it took for the “first pain episode” in the BuTrans group was 21 days.  So BuTrans did better than placebo.

The second study was more interesting, but smaller.  It was more interesting because it compared BuTrans versus an established pain killer.  Unfortunately being a smaller study, we are less confident about the results.  The study looked at lower back pain.  It only had 134 patients in it, but it looked at BuTrans, oxycodone/acetaminophen (Percocet, oxycocet) and placebo.  Again BuTrans was better than placebo, but that wasn’t a big surprise. The part I found more interesting was BuTrans seemed to be a similar strength pain killer as taking 2 tablets of oxycodone/acetaminophen four times a day.  So if a patient required 2 tablets of oxycodone/acetaminophen four times a day for over six months to treat their lower back pain, their doctor may be able to switch them to one BuTrans patch every week instead.

The third thing that surprised me about the marketing of BuTrans is the company, Purdue, is aiming BuTrans at opioid naïve patients.  Opioid naïve patients means they haven’t had any narcotics before.  For example 80% of the patients in the lower back pain study mentioned earlier were opioid naïve.  In contrast, the fentanyl patch, must only be used in someone who has tried other weaker narcotics before.  It usually goes something like this: the patient gets a fast acting narcotic pain killer like morphine which is given 4 to 6 times a day.  Once the doctor figures out what dose controls the patient’s pain, they are converted to long acting morphine that can be given twice a day.  If the pain control remains stable, the patient is then converted to the fentanyl patch which only needs to be changed every three days.

The side effects of BuTrans are similar to other narcotic pain killers and include nausea, vomiting, dizziness, sleepiness, constipation, itchy skin and dry mouth.  Not everyone will get every side effect.  Effects like nausea, vomiting and sleepiness are common at the start of taking a narcotic pain killer, but go away as you get used to the medication.  Effects like constipation will usually last as long as you are on the medication and should be treated with stool softeners.

Now the bad news.  BuTrans is new which means it is not paid for by pharmacare, Indian Affairs, Social Assistance or any insurance company I am aware of.  That will probably change over time, but as with most new drugs, there is no coverage yet.  And it isn’t cheap.  BuTrans can run from $70 to $200 a month depending on the strength you need.

 As always if you have any questions or concerns about these or other products, ask your pharmacist.

Update May 27/11 Got an email from someone who said Pacific Blue Cross partially paid for his butrans in Canada.  So maybe the insurance companies are starting to pay.  Anyone else have any thoughts?

BuTrans – Audio

By Trevor Shewfelt.  Recorded by the nice people at 730 CKDM, The Parkland’s Best Music

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Compounding – Audio

By Trevor Shewfelt.  Recorded by the nice people at 730 CKDM, The Parkland’s Best Music

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Custom Compounding

 

By Trevor Shewfelt, Pharmacist at the Dauphin Clinic Pharmacy

We now have this and most other articles published in the Parkland Shopper on our Website.  Please visit us at www.dcp.ca

The information in this article is intended as a helpful guide only.  It is not intended to be used as a substitute for professional advice.  If you have any questions about your medications and what is right for you see your doctor, pharmacist or other health care professional.

My mom has a picture of me with my dad, Bob, my grandfather, Stan and my great-grandfather Tom.  I was very young in the picture and I don’t remember meeting Tom.  But at least I was alive at the same time as him.  I don’t know anything about Tom’s dad, my great-great grandfather.  Now imagine if my great-great grandfather without writing it down, could somehow give me the knowledge of how to get to a secret cabin in the woods.  Remember, were never alive at the same time.  Sounds a little like science fiction, doesn’t it?  Well that’s exactly what Monarch butterflies do!

Monarch butterfly generation one is born in Mexico flies north to the southern US, mates and dies.  Generation two flies from the southern US to the northern US, mates and dies.  Generation three flies from the northern US to Canada, mates and dies.  Each of these three generations lives only about a month.  Now generation four is special.  Obviously this is because it is Canadian.  Generation four lives for about 9 months.  Nine times longer than each of the previous generations.  But the really incredible thing is generation four flies all the way back to Mexico.  It flies over 3200 km.  It seems to know where to go even though it never flew it before.  In fact no butterfly has flown the trip in four generations.  Just like if my great-great grandfather passed the knowledge of the location of the secret cabin in the woods to me.

Other useful knowledge from the past is custom compounding.  Custom compounding is when a pharmacist mixes together a preparation that isn’t commercially available for a patient at the direction of a physician, vet or dentist.  In the past, a lot of what pharmacists did was compounding because there weren’t that many commercially available medications around.  Now most pharmacies dispense pre-fab pills.  However, there are some pharmacies that have retained the knowledge from the past of how to customize a medication for a particular patient.

At the Dauphin Clinic Pharmacy, we have taken the arcane knowledge of compounding and given it a modern twist so we can tailor medications to an individual patient’s needs.  For example, we made a topical version of lorazepam for a nursing home patient.  Lorazepam can be used to calm someone who is very agitated.  But, as you can imagine, trying to give a pill to someone who is very agitated and has dementia can be difficult.  Sometimes the nurse even gets bitten.  There is an injectable version of lorazepam, but again it is difficult for the nurse and distressing for the patient.  But, holding an agitated patient’s hand and rubbing a medication on their wrist is a very natural and calming thing for a nurse to do.  So, we made a topical version of lorazepam so the nurse could rub into onto the wrist.  It worked well for both nurse and patient.

For animals, under a vet’s direction, we have made a variety of products.  We have made everything from injections for cattle to liquid antidotes for dogs who ate rat poison.  One interesting thing we compounded was an antibiotic for a cat.  We started with a human medication, ground it up an put it into a special fish paste that the cats love.  However, we found one cat didn’t like fish, so that cat gets its medication in a chicken paste.  When the patient is a cat, it is still important to listen to the patient’s needs.

Any one who has had hemorrhoids will tell you how annoying, painful and itchy they can be.  The problem is most suppositories slide right by the hemorrhoid and so they don’t release much of their medication onto the hemorrhoid.  At the Dauphin Clinic Pharmacy we have a suppository mold called a Rectal Rocket.  It flares at both ends so the suppository stays where it can do the most good.  And, of course we can customize which medications we put in the suppository.

So just like the Monarch Butterflies, we have received our compounding knowledge from our pharmacy fore-fathers.  Then we put a modern twist on the knowledge of compounding and with it we can help our patients by customizing their medications to their specific needs. 

 As always if you have any questions or concerns about these or other products, ask your pharmacist.

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