Buprenorphine Conversions
https://www.practicalpainmanagement.com/treatments/pharmacological/buprenorphine-conversions
While the original launch of the free PPM online opioid calculator in 2012 did not include any conversions to or from buprenorphine due to its complex pharmacology and pharmacokinetics (see below), these conversions were eventually added as several clinicians requested access to the calculation data in order to transition patients to a safer opioid alternative.
Unlike full agonist opioids, buprenorphine has a ceiling, or plateaued, effect on CO2 accumulation. It is important to note that the addition of buprenorphine, including transdermal patches and buccal films, to this calculator came with a preprogrammed conversion ceiling and a warning that conversions to or from buprenorphine could not be recommended. For example, if a user asked to convert morphine 80 mg orally to buprenorphine film (Belbuca), they would receive a warning “Result exceeds maximum daily dose. Patients on morphine 80 mg PO (or equivalent) or higher, must not receive Buprenorphine (BF) due to possible opioid withdrawal risk.”
Fast-forward to the contemporary opioid environment of 2018-2019, where ubiquitous state and federal policies and guidelines continue to push for safer alternatives. In addition to the 2016 CDC Guideline for Prescribing Opioids for Chronic Pain, which cautions clinicians about morphine equivalent doses (MEDs), a new 2019 CMS rule will implement soft and hard edits at 90 MEDs and 200 MEDs, respectively.
Neither the CDC nor Medicare cites buprenorphine as having an MED.
Therefore, buprenorphine has been removed from the online calculator due to the following factors:
- Buprenorphine is now more commonly considered a safer opioid alternative with efficacy often comparable to or superior to its full agonist cousins (its diminished risk for respiratory depression may also provide safety advantages compared to full agonists)
- Prescribing clinicians are often evaluated or tracked based on their MED prescribing habits
- Current clinical guidelines seem to align with the position that buprenorphine should not be assigned any MED.
With this change, it is hoped that clinicians may recognize the unique attributes of buprenorphine and see it as a valuable option that does not have a calculable MED by acceptable guidelines.
The complexities of buprenorphine
From a practical perspective, buprenorphine cannot have a linear conversion to/from morphine (or an equivalent) because of its complex pharmacology and pharmacokinetics, including:
- Buprenorphine has a higher binding affinity to mu-receptors compared to every full-agonist opioid prescribed for in-home use as well as naloxone (Narcan)
- The buprenorphine parent molecule is considered a partial mu-agonist, but will nevertheless overcome receptor binding by concomitant full agonist use
- Because of #2, at 80 to 90 mg of morphine equivalent dose (MED), patients may experience withdrawal as the full agonists are displaced by buprenorphine mu-receptor occupation.
– PPM Editors-at-Large Jeffrey Fudin, PharmD, and Jeffrey Gudin, MD (December 2018)
Filed under: General Problems
[…] Neither the CDC nor Medicare cites buprenorphine as having an MME […]
I was converted to sublingual buprenorphine 10 years ago for chronic & acute pain, after weaning myself off fentanyl & dilaudid. It works well. One aspect no one talks about is the damage this med does to your mouth/teeth – significantly reduced saliva and extreme pH changes (to 3.4 pH). I now need ALL teeth extracted surgically with accompanying expensive prosthodontics. No one ever let me know this risk or side effect.
I am currently struggling with this. My doctor wants to stay at or below 50 mme, for whatever reason this is within her comfort zone. Months back I was taking 300mcg belbuca, the sublingual form of buprenorphine. I wanted to go up to 450mcg to see if that would help my pain or go up on my breakthrough medication, hydrocodone. She is currently giving me 3X 5mg of hydrocodone a day for breakthrough pain which I definitely use everyday. I finally found a conversion chart that showed her that 450mcg equated to 13.5 mme. So if she did go up for me it would be 450mcg x 2 a day equaling 27 mme plus 15mg of hydrocodone equaling 15 mme which would be 42 mme total. She hesitated but finally said yes. Does this mean that in counting my daily mme I should only count the hydrocodone according to the CDC? There’s not much literature to support how this should work. There is no contradiction in prescribing full agnostic opioids with the buprenorphine and has been done successfully as long as you stay relatively low on the full agnostics and do not go to high on the buprenorphine. Any information anyone has seen on this would be fantastic. I feel like they see it as either all bupe or all full agnostics and with it being used as a pain medication as well as an addiction medication they are missing a portion of the community that uses it differently.
it seems like this bup is the new drug of choice this week My dr asked me if I wanted to try it because there was no mme limit. He said one he is talking about doesnt have the “opioid blocker” in it it is a pain medication. With all the games being played today im afraid if I try the bup which is a film and it doesnt work as good as my pain meds,will I be able to get my pain meds back? Or will that be what they are looking for and close the door on pain med I was on for over 25 years?
To @iamfcbh. I would not recommend you switch UNLESS your current medicines are not working. The reason bupe has no MME limit is because it has a natural “ceiling” effect. Also, most people with chronic pain find that it works for a few weeks and then stops. It doesn’t work as effectively as full mu-agonists.
Again, I would NOT do it! And no, I don’t think your doctor is being fully transparent with you, so I think getting your old rx back would be a huge struggle or impossible.
I absolutely agree don’t switch!!! The last time years ago I was basically forced to try a different med when it didn’t work and I found out not covered under insurance I requested my other meds back that were working somewhat. He refused and put me through hell. I of coarse left that Dr and found my Dr that left who originally wrote for the other meds and the doses I was on that worked. And did well for couple years till she left again and the new Dr cut my doses and again I suffered this happened 3 more time till the last time she left I had to find different Dr who I’m currently with. He ordered my original meds and doses and I did well till 2016 guidelines came out meds cut and starred in morphine lowered to 60 mme and I’m in hell.