Pt’s statements in RED: My words are in Green
Remember she is doing speech to text
This disabled female pt reached out to me Aug 4th and her doc had just abruptly cut her oral opioids she had been taking for ~ 10yr from 90 MME/day to 30 MME/day and put a Buprenorphine patch on her the next day. This is just starting to evolve but I am going to leave this post at the top of the first page and update as things happen – STAY TUNE
This is Aug 5th:
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. Oxycodone
This. Kinda. Has. Me. Scared
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 10
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 10 mg twice a day and then he started me on the patch. I Am. Shaky nauseated
My body is used. To 15. Mg 4 times a. Day. For at least 10years
10 mg 2. Two. Time. A day
If this is with drawl. 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.
Aug 7, 2025, 9:05 AM
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
Is your doctor just an employee of a large hospital system. I would like to put a spot light on his employer – let me know
Yes no. He works in a private practice 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. I told my daughter if I die go after. Him he. And. One another Dr
Aug 8, 2025, 2:38 PM
Now. I am. Super. Sick and Allie want. To. Do is. Sleep
Just took. My blood. Presdure229/117 I thought my daughter. Was. Going to. Have to. Call. A. Squad. For me. My right arm. Was killing me
I think it’s this medicine because as soon as this patch got into my system because it said it took two days my blood pressure went sky high because I had been at my oncologist and it was good. It was only one 10/90 and then as soon as I put this patch on that he prescribed it’s been Scott ever since.
They just keep up with my blood pressure medicine. It’s crazy.
If it doesn’t come down by Monday, I’m calling his office. I’m telling him I’ve taken off his patch.
Maybe my body cannot tolerate these patches
All. I want to do is. Sleep my. Head. Hurts. I can’t. Eat. Fill. Like. Freaking shit
It has my granddaughter. Freake. Out she keeps. Coming in my. Room. To check. On me
Cause like I laid on the couch after I got her from school at volleyball at 11:30 I did not wake up till 730. That is not like me. I’m very involved in all of their kids like grandkids sports and I missed a volleyball game and so she knows that’s not like a lady I see at McDonald’s today for my granddaughter. She said that I didn’t look very well and asked was I not feeling good I said my doctor trying to move medicines around.
Then they’ll probably say I’m a drug seeker that would be my luck
I just don’t understand my pain doctor. I personally feel he should’ve said well. I’m cutting you down. Let’s try one a month then the next month or two month then go to the tanks 321 but no he goes in and he I just walked in and he’s like I’m cutting you down and putting you on these patches
Thank. You
The cardiac. Lab. Can. Vouch too. They wanted to do a stress test but couldn’t because this is when my blood pressure started going up the cardiologist. He’s like we’re not even gonna try it. He’s like take the IV out. Send her home.
If I don’t. Strat. Doing better. By Tomorrow. I will go to Emergency
Maybe both how many other. Patients. Has. Done. It To. Beside. Me
If this is withdrawal, I don’t know how people can go through it like I personally feel like I’ve been hit by a Mack truck
I have been on 15 mg four times a day for 10 years at least
I have a broken back the knee replacement my shoulders won’t move. I have blown disc all through my spine, so I’m the hot mess express with pain things.
It came. Down to 170/110after I took. Patch off after 3. Hrs now going backup again
5 mg 2. Times a day
OK, I left right now. Definitely an eight.
It. Stayed. At 8
3. During the day. And. I took. One at bedtime
I. Did. When I. Was. On the. 15. It. Got me. To 5
And. My blood. Pressure Was. Never this. High
When I woke. Up. I took. It
They. Would last. Me. I. Go to bed. At 10 and wake up. Around 6. And I. Would need. It. Cause I would be. Hurting. So. Bad
When am moving around. It would. Wear. Off. In. 3 hrs
My. Dr. Is. One. Sided. He. Don’t. Listen. I have been on. 15. For. At least. 10 plus years
It just. Don’t make. Sense how. Are you. Going to do this. To. A. Person who. Is. Used. Yo. Taking. 15 mg 4times. A Day. To. 5 2. Times. A. Day I just. Can’t. Understand. It how. Many people. Has. He. Done. It 2
It would have made more sense if he had maybe taken one down then the next month take another down then the next one take it down again then cut me down to the five and I have been on these at least 10 years like I still feel like shit, headache unbelievable
I understand he went to school for so many years I don’t want to lose his license cause he always talks about his children and his wife and sports But man, oh man, he’s really making me feel like shit
That’s what I thought. He should’ve started taping me down instead of A sudden
I am. Going to call. Him. Monday. I am. Sure. He. Won’t give a. Freak
What should I say to him?
That my blood pressure is off the chart. I have a headache. They couldn’t even do a stress test cause it’s so high. I feel like my skin is kind of crawling. I’m nauseated. I took off the patch cause I thought maybe that’s what was doing it.
Took. My blood. Presdure180/ 120
What kind of made more sense if he cut me down one a month or something like this is torture
Iwl. Before I go to bed
I. Just took the5. On. An empty stomach’s
205/90 my heart is. Beating. 90
Yes my. Daughter. Is. Very. Smart. With. Computer iwill. Ask. Her
I. Just. Want my headache. To. Stop
My blood. Pressure. Was 189/120. And my pulse was 110
8 at least
Aug 10, 2025, 9:44 AM
A day or two after she put the buprenorphine patch on she was scheduled to have a treadmill cardiac stress test. Before the test, they took her blood pressure and it was 240/120 – what the American heart Association claims is a hypertensive crisis level. This test was done in part of a hospital system. Of course the stress test was cancelled, and the staff just SENT HER HOME. Before she had the patch on, her blood pressure was more normalish. Here is the American Heart Association on its definition of blood pressure. You may have to click on the graphic TWICE to make it enlarge and more readable
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Filed under: General Problems
Why is there all these ways to switch people to bupe in the 1st place when they were doing absolutely fine on whatever they were already taking? From all I’ve seen and heard, it doesn’t work at all or even close to other full agonist opioids so why the change?
IMO, the prescribers believe that it is a “safe harbor” until the DEA finds out that the pts getting bupe are going out on the street and exchanging it for the drug they want. Apparently believing that it is safer prescribing a C-III, BUT they forget that prescribing a Benzo a C-IV IS NOT SAFE!
Buprenorphine seems to be getting a bad rap when it comes to chronic pain patients. I agree that the oral film you put in on the inside of your mouth is bad and should be pulled from market. My question…does the patch, when used specifically for pain , do anything for chronic pain. Especially when there are different levels of chronic pain. Some patients may have severe chronic pain like can’t get out of bed pain. Or some patients have moderate or mild chronic pain that is irritating but they can function in most settings such as go to work, do grocery shopping. Thanks for letting me reply…
90mme to 30mme. That’s below most documentation I’ve seen mandating specific levels. I believe that 50mme was the bottom that the updated 2022 CDC Guidelines and CARA 2016 promoted. Regardless, that’s not in anyway condoning this draconian reduction and I thank you for sharing her story.
I really feel sorry for this lady. I can’t believe how fast they dropped her dosage, and with no warning. It’s not supposed to be more than a 10% change per week, or longer if needed. Doctors can write for 90 mme if they feel it’s appropriate, have plenty of documentation, and it’s in the normal course of their duties, thanks to the SCOTUS ruling in Ruan v United States. I hope if she went to the ER, they referred her to a good pain doctor, because it honestly sounds like the buprenorphine patches are causing some sort of cardiac issues. If a cardiologist won’t do a stress test on you because your BP is too high, that’s bad! I hope things get straightened out for her! ❤️
Why was she lowered or changed to different med when she was stable already?
educated guess— the DEA had told him directly and/or he attended some meeting where the DEA made a presentation – if you don’t want to lose your license …you will put all your pts on Buprenorphine patches. IMO, in this particular case with this woman, this doctor did not even come close to the standard of care and best practices. To wean a pt down on Oxycodone and transition a pt to buprenorphine.
Transitioning a patient from 90 MME/day oxycodone to buprenorphine requires careful adherence to evidence-based protocols and a clear understanding of the pharmacology involved. The best practices emphasize patient safety, minimizing withdrawal and avoiding precipitated withdrawal.
Standard of Care
The traditional STOP-START induction involves discontinuing full opioid agonists (like oxycodone) for 12-24 hours, waiting for the onset of mild to moderate withdrawal symptoms, and then starting buprenorphine (typically sublingual, mg-strength) dosing.
Recent best practices for high-dose opioid transitions (>90 MME) recommend close monitoring and may use initial buprenorphine dosing strategies of titration after withdrawal symptoms appear, with frequent clinical reassessment.
An alternative, low-dose or microdosing (Bernese method), initiates buprenorphine (often mcg or very low mg doses) while the patient continues the full opioid agonist, slowly increasing buprenorphine and tapering the other opioid, to minimize risk of precipitated withdrawal and manage discomfort.
Best Practice Recommendations
Assess stability and risks: Identify opioid use disorder (OUD), other behavioral risks, and patient stability. Monitor closely during transition, as high-dose chronic opioid patients may stabilize on lower buprenorphine doses than those with OUD.
Patient preference: Involve the patient’s preferences in selecting between traditional withdrawal-based and low-dose/microinduction techniques.
Formulation selection: For 90 MME/day, typically sublingual buprenorphine (mg dosing) or buccal film (mcg dosing) is used; patch is less preferred at higher doses.
Naloxone co-prescription: Always provide naloxone and education about overdose risk during and after transition, especially if reverting to full agonists.
Adjuvant support: Continue non-opioid analgesics and comfort measures to manage withdrawal symptoms when needed.
Protocol Overview
STOP-START (traditional): Discontinue oxycodone, wait 12-24 hours for mild-moderate withdrawal, then start 2-4 mg buprenorphine SL, titrate upward.
Low-dose/microdosing: Begin 0.2-0.5 mg buprenorphine SL or buccal mcg doses while maintaining opioid, gradually titrate buprenorphine up and other opioid down over 3-7 days.
These protocols can vary by formulation, clinical scenario, and institutional guidelines. Frequent reassessment and patient-centered modifications are critical for safety and efficacy.
References
For detailed tables and sample conversion schedules, see the VA guidelines and recent review articles.
This approach closely follows current standards and published guidelines for converting from high-dose oxycodone to buprenorphine, prioritizing withdrawal mitigation and patient function.
Dr. Steve, That ought to be a very interesting case! I’m looking forward to reading about it with my coffee to see how it unfolds and what happened to the poor lady
❤️