If a long term intractable chronic pain pt was to be taken off their oral opioids and put on buprenorphine patches. Why would any practitioner would take a intractable chronic pain pt off of oral opioids that apparently were working well and the pt’s total MME/day was 90. Besides such a irrational thought of stopping a intractable chronic pain pts oral opioids. There is a suggested process in properly transitioning a pt from oral opioids to a buprenorphine patch and I asked perplexity.ai what the process is so that I would not miss a step or two, regurgitating it from memory. Besides the FDA made the following statement about the potential harm to pts from rapid dose reduction. IMO, reducing a pt’s opioid dose by 66% and concurrently put a buprenorphine patch on the pt, is about as close to moronic as one can come. This pt’s BP quickly elevated to 240/120. Defined by the American Heart Assoc as Hypertensive Crisis Level. And below is a graphic that outlines the damage to the human body from untreated high blood pressure. That has always been known as “the silent killer”.
The FDA is now requiring that opioid labels emphasize the importance of avoiding rapid dose reduction or abrupt discontinuation in patients who may be physically dependent on opioid pain medicines, as it can cause serious harm.
Can we thank HHS Secretary Robert F. Kennedy, Jr. f
or this new PROHIBITION?
From a chronic pain pts interaction with their pain doc!
Well. I. Just. Saw my pain. Dr. He’s. Putting me on. bupe patch. He said. I am. On. Way. To high. Of. opioids I take 90 MME/day.. I am confused
He put me on… Suboxone patches, because I am on way to high of opioids trying. The Patches I am. Kinda. Scared. As. My body reacts crazy. To some meds. Morphine. put me in a coma, I almost died.
Wow. He. Kinda. Has. Me. Against the. Wall. I can’t. Say. I am. Not trying Cause if I did. He. Would. Say. Bye he had. Never. Mentioned. Anything he was. Like. I am. Putting you. On. This. Patch and I am. Cutting. Your. oral opioids
This. Kinda. Has. Me. Scared Would you try it personally?
He did not tell me anything. He just said we’re gonna I’m cutting you down and here’s a patch. I’m putting it on and that’s all you said.
Me and my primary care doctor were talking about that he said the DEA is probably pushing on him to cut people back because he had never mentioned it at all and I’ve been seeing him probably three years. He’s in a practice by him while he’s got other doctors, but they’re not to my knowledge. He’s not affiliated with any hospitals. It’s just a practice.
You. Know what I just. Looked. At. My. Bottle. He. Cut me. Down. Monday. When. I saw. Him. To 15 MME
That explains why, but don’t you think he should have said something to me
Like hey. I am. Cutting. You down. Now
He cut me down to 1/3 twice a day and then he started me on the patch. I Am. Shaky nauseated
My body is used. To THREE TIMES over 4 times a. Day. For at least 10 years
If this is withdrawal. Ugh
Sorry, didn’t mean to do that, but yeah, it’s horrible nauseated feel like I’m gonna throw up shaken, lightheaded all the above
When they tried to do a cardiac stress test, my blood pressure was 240/120. The cardiologist said no you got a discontinue to figure another way to and they already sent a report. There’s all kinds of things, my heart and even the doctor in the nurse, they said I’m probably going through withdrawals.
My. Primary. Just upped my blood. Pressure meds he said. It could ending up having. A stroke
Could it be the patch. Causing my blood. Pressure. Going. Up. So. High
I have never. Been. This. Sick. And my. Blood. Pressure. Won’t. Come. Down
I told my daughter if I die go after. Him he. And. One another Dr
what is proper procedure moving a pt from a opioid to a buprenorphine patch, should the pt be weaned down some or should the pt be opioid free for a couple of days
Transitioning a patient from a full opioid agonist (like morphine, oxycodone, or methadone) to a buprenorphine patch requires careful planning to avoid precipitated withdrawal due to buprenorphine’s high receptor affinity and partial agonist effects. The correct procedure depends on the clinical scenario, opioid used, and whether the goal is treatment of pain or opioid use disorder.
General Procedure
Traditional (Standard) Induction
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Opioid-free period recommended: For most full opioid agonists, the standard advice is to have the patient discontinue their current opioid and wait until they show early to moderate withdrawal symptoms—generally, 12–24 hours after the last dose for short-acting opioids, and up to 36–48 hours for longer-acting opioids like methadone.frontiersin+2
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Withdrawal should be measured clinically, for example with a Clinical Opiate Withdrawal Scale (COWS) score of at least 11–12 before buprenorphine initiation.ccjm+1
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Why?: Starting buprenorphine too soon can precipitate withdrawal because of its partial agonist/antagonist properties.
Microdosing/Cross-Taper (“Low-Dose” Initiation)
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No opioid-free period required: In low-dose (microdosing) protocols, buprenorphine is started at a very low dose, while the patient continues their full opioid agonist. The buprenorphine dose is gradually increased (“cross-tapered”) over several days, and the full agonist is then tapered down and discontinued.mypcnow+3
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Example protocol: Start with a low-dose buprenorphine patch (e.g., 20mcg/hour), add additional patches over 2–3 days, and introduce low-dose sublingual buprenorphine while continuing full agonist opioid. The full agonist is then tapered off as buprenorphine replaces it.bridgetotreatment
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This approach may be especially useful for patients with high pain needs, on high-dose opioids, or for those who struggle to tolerate withdrawal symptoms.
Special Note for Buprenorphine Patch in Pain Management
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For chronic pain (as opposed to opioid use disorder): Many guidelines indicate that tapering the patient’s opioid dose is recommended, but a complete opioid-free interval may not always be required for pain patients when switching to a buprenorphine patch at appropriately low doses. Still, transitions should be monitored closely, as there is still a theoretical risk for withdrawal, especially at higher opioid doses.academic.oup
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Start at a low buprenorphine dose: Buprenorphine patches come in microgram (mcg/hour) doses and should be titrated upwards slowly with clinical monitoring.va
Practical Recommendations
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Taper opioid dose, if possible, to the lowest effective dose before transition, particularly when switching from methadone, as precipitated withdrawal risk increases with higher doses.frontiersin+1
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For standard induction: Wait 12–24 hours (short-acting opioids) or 36–48 hours (methadone) opioid-free until the patient has at least moderate withdrawal.
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For microdosing/cross-taper: Overlapping with full agonists is possible under specialist guidance, especially useful when an opioid-free period/waiting for withdrawal is intolerable or risky for the patient.pmc.ncbi.nlm.nih+2
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Close monitoring is essential during any transition, watching for withdrawal symptoms, adequate pain control, and potential adverse effects.
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Consult specialist protocols or pain/palliative care experts when in doubt, especially for complicated cases or high-dosage opioid users.superiorhealthqa+2
Summary Table: Transition Methods
| Method |
Opioid-Free Interval Required? |
Typical Protocol |
Best For |
| Standard Induction |
Yes (12–48h, see above) |
Stop opioid, initiate BUP in moderate withdrawal |
OUD, most patients |
| Microdosing/Cross-taper |
No |
Gradual, overlapping low-dose BUP while tapering opioid |
Pain management, complex pain |
Bottom line:
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If using the standard approach, patients must be in withdrawal before initiating buprenorphine patch to avoid precipitated withdrawal.
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If using a microdosing or cross-taper protocol, an opioid-free period is not required—these can be effective and better tolerated in certain pain populations, but require close monitoring and preferably specialist input.jom.osteopathic+4
- https://www.frontiersin.org/journals/pharmacology/articles/10.3389/fphar.2021.718811/full
- https://www.va.gov/formularyadvisor/DOC_PDF/CRE_Buprenorphine_for_Chronic_Pain_MAR_2024.pdf
- https://www.ccjm.org/content/90/9/557
- https://www.mypcnow.org/fast-fact/buprenorphine-initiation-low-dose-methods/
- https://jom.osteopathic.org/abstract/successful-buprenorphine-transition-while-overlapping-with-a-full-opioid-agonist-to-treat-chronic-pain-a-case-report/
- https://bridgetotreatment.org/wp-content/uploads/CA_BRIDGE_SITE-EXAMPLE_Starting-Buprenorphine-with-Microdosing-and-Cross-Tapering_June_2025.pdf
- https://pmc.ncbi.nlm.nih.gov/articles/PMC8595358/
- https://academic.oup.com/oncolo/article/29/11/e1593/7717083
- https://www.superiorhealthqa.org/resource/buprenorphine-for-pain-a-transition-guide-from-full-agonist-opioid-prescriptions/buprenorphine-initiation-guide_v3_508/
- https://www.nhs.uk/medicines/buprenorphine-for-pain/how-and-when-to-use-buprenorphine/
- https://medlineplus.gov/druginfo/meds/a613042.html
- https://jeccr.biomedcentral.com/articles/10.1186/1756-9966-28-61
- https://accpjournals.onlinelibrary.wiley.com/doi/10.1002/phar.2676
- https://www.samhsa.gov/sites/default/files/quick-start-guide.pdf
- https://www.asam.org/docs/default-source/education-docs/unobserved-home-induction-patient-guide.pdf
- https://www.sciencedirect.com/science/article/pii/S2772724622000798
- https://www.ncbi.nlm.nih.gov/books/NBK459126/
- https://www.ema.europa.eu/en/documents/product-information/suboxone-epar-product-information_en.pdf
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Why no mention of the tooth loss associated with Suboxone ?
Buprenorphine is also linked to tooth loss, the Suboxone oral strips are the worst, but all of them cause this issue, just Google the lawsuits.
I personally know a pain patient who had perfect teeth, was put on Suboxone, and now is getting full dentures.
Thee are many other patients who this has happened to, a number of class action lawsuits.
This woman’s Dr is paranoid, and wants to reduce his liability.
Notice no mention was made by him to her about her teeth falling out with the Suboxone, he cares more about his MME count than his patients.
My Pain Mgmt Dr keeps bringing up buprenorphine too, so far I have been able to refuse.
The tooth rot you are describing is mostly from the strip that is used in the mouth, I believe the topical patch is less so and that is what the so called doctor was putting her on.
Is some bloggers in need of improving their English skills?
It is so understanding of you, the parts of the blog post – that I believe are being critical of – was from an intractable chronic pain pt who had been thrown into a basically a cold turkey withdrawal and a hypertensive crisis blood pressure, and using talk to text. I approved your comment and left it up so that my readers can see how some people are extremely critical of others and not knowing or understanding what they are dealing with
Years ago I was tapered and put on A patch called Butrans! It’s the Name Brand of bupenorphine. That works good for pain relief, but then my insurance wouldn’t pay for the Name Brand anymore. So I had to switch to the generic. THAT was garbage!!! It didn’t do anything!