Jul 2, 2010

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 doesnt say severe pain, and it doesnt 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 wasnt 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 nave patients. Opioid nave patients means they havent had any narcotics before. For example 80% of the patients in the lower back pain study mentioned earlier were opioid nave. 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 patients 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 isnt 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?


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