Buprenorphine for pain

Buprenorphine is a strong opioid medicine. It's mainly used to treat moderate to severe pain, for example during or after an operation or a serious injury, or pain from cancer.

It's also used for other types of long-term pain when weaker painkillers have stopped working.

It works by blocking pain signals between the brain and the rest of the body. It also reduces the anxiety and stress caused by pain.

It can also be used to treat drug dependency, but this is usually prescribed by a specialist.

Buprenorphine is only available on prescription. It comes as:

• patches to put on your skin
• tablets that dissolve in your mouth
• injections – usually only given in hospital
• implants that are inserted under the skin of your upper arm – only used for drug dependency

Most adults can use buprenorphine. Children can sometimes use it if a specialist doctor recommends it.

Buprenorphine is usually only recommended when weaker opioids for pain stop working for you.

Your doctor or pharmacist will work out how much buprenorphine to give you, depending on why you're using it and what dose of other opioids you've had.

Buprenorphine is not suitable for some people. To make sure it's safe for you, tell your doctor or pharmacist if you:

• have ever had an allergic reaction to buprenorphine or any other medicine
• have breathing difficulties such as asthma or a lung condition
• have sleep apnoea
• drink a lot of alcohol, or are addicted to alcohol or drugs
• have a head injury
• have a condition that causes fits or seizures
• have an irregular heartbeat (arrhythmia)
• have kidney or liver problems
• have low blood pressure (hypotension)
• have an impaired gut or bowel (paralytic ileus)
• have long-term constipation
• have myasthenia gravis (a condition where muscles become weak)
• are trying to get pregnant, are already pregnant or breastfeeding

Buprenorphine for pain comes in different strengths, depending on the type:

• patches release 5 micrograms, 10 micrograms, 15 micrograms or 20 micrograms every hour for 7 days, or 35 micrograms, 52.5 micrograms or 70 micrograms every hour for 3 or 4 days
• tablets contain 200 micrograms or 400 micrograms

Doses vary from person to person. Your dose will depend on:

• what you're taking it for
• how bad your pain is
• how you've responded to other painkillers
• whether you get any side effects from buprenorphine
• whether you're taking other medicines

Before taking or using buprenorphine, you'll usually start on a low dose of another type of opioid, such as morphine. This is increased slowly until your pain is well controlled.

Once your pain is under control, your doctor may swap you to buprenorphine patches. This will avoid you having to take tablets each day.

If your doctor agrees that you can stop taking buprenorphine, they'll reduce the strength of your patch gradually. This is especially important if you've been taking it for a long time. It will reduce the risk of withdrawal symptoms.

Your doctor may switch you to morphine tablets or liquid or another similar painkiller so they can reduce the dose even more slowly.

How often you take or use buprenorphine depends on the type that you've been prescribed.

Patches

Apply a new patch every 3, 4 or 7 days, depending on the strength and the brand you've been prescribed. Always remove the old one first.

Sometimes your doctor may prescribe a buprenorphine patch with another painkiller. This is to manage sudden flare-ups of pain that break through the relief the patches give.

Do not apply more than 1 patch at a time, unless your doctor tells you to.

Using more patches than recommended could lead to a fatal overdose.

1. Read the instructions that come with your patch carefully.
2. Remove the patch from the packet. Do not cut patches unless your doctor has told you to.
3. Peel off the plastic from the back of the patch. Do not touch the sticky side of the patch.
4. Apply the patch to clean, dry, flat, undamaged skin. Do not touch the sticky side of the patch. Choose somewhere you can reach easily such as the top of your chest or top of your arm. Try to avoid very hairy areas, or trim the hairs first before applying the patch. If you find shaving easier, shave the area a few days before you apply the patch to make sure shaving does not irritate your skin.
5. Press the patch against your skin for at least 30 seconds. Make sure it sticks well, especially the edges.
6. If your doctor tells you to use more than 1 patch, follow the instructions that come with the patches. Do not let the patches overlap on your skin.
7. Do not cover the patch or patches with anything including a dressing or tape. Talk to your doctor or pharmacist if you find your patch does not stick very well.
8. Wash your hands after touching a patch.

Do not expose your patch to strong heat or sunlight while wearing it, as this can increase the amount of buprenorphine that gets absorbed into your skin and can increase the risk of side effects or overdose. This includes long hot baths, saunas, electric blankets, hot water bottles, heat pads and sunbathing.

You can have showers or baths and go swimming. Check the patch is still on properly afterwards and dry the area around the patch carefully.

Changing your patch

When you replace a patch, fold the used patch in half with the sticky side inwards and put it in the empty packet from your new patch. Ask your pharmacist how to dispose of your used patches.

When you change your patch, try to do it at the same time of day. Think of ways to help you remember when to change it. You could:

• write the details on your calendar
• write the time and date on the surface of the patch itself (using a soft-tip permanent marker pen)
• use a phone app or smart speaker to record the time

If your patch falls off

Check your patch every day to make sure it stays stuck to you, especially around the edges.

If your patch is missing, make sure it has not stuck to another person, especially a child, by accident – for example if it falls off in bed or if the patch falls on the floor.

It's important to find it then fold the patch in half with the sticky side inwards. Keep it safe until you can dispose of it safely. Ask your pharmacist how if you're not sure.

If a patch falls off before you need to change it, put another patch on a different part of your body and put the old patch back in the packet it came in.

For patches that you normally change after 7 days, change the replacement patch on your usual day and time. For example, if you normally change your patch on a Monday and it comes off on Wednesday, replace it on Wednesday and change it as usual on Monday.

For patches that you normally change after 3 or 4 days, make a note of the day and time when you put on the replacement patch. Then change the patch again after a further 3 or 4 days as usual.

• a buprenorphine patch sticks to someone it has not been prescribed for

If this happens, remove the patch straight away.

Check the information leaflet for how to take buprenorphine tablets. Depending on which type of tablets you have, you'll either put them under your tongue or on your tongue. Let the tablets dissolve in your mouth. Do not swallow them.

The information leaflet will also tell you whether you can take the tablets with food.

Take tablets when you need them for pain relief. Each dose will usually last 6 to 8 hours. Talk to your doctor if this is not controlling your pain.

Depending on why you're using buprenorphine, you may only need to use it for a short time.

For example, if you're in pain after an injury or operation, you may only need to use buprenorphine for a few days or weeks.

You may need to use it for longer if you have a long-term condition.

Keep all types of buprenorphine in a safe place and out of reach of children or vulnerable adults.

Used patches can still contain buprenorphine that can be dangerous. It's important to fold a patch in half with the sticky side inwards after you've taken it off. Keep it safe until you can dispose of it safely. Ask your pharmacist how if you're not sure.

If you miss a dose, what to do will vary depending on which type of buprenorphine you're using.

Tablets are usually only taken when you need them so you're unlikely to forget. However, if you're unsure what to do, ask your pharmacist or doctor for advice.

Never take 2 doses at the same time. Never have an extra dose to make up for a forgotten one.

If you forget to apply a patch, check the information on the leaflet inside the packaging, or ask your pharmacist or doctor for advice on what to do.

Always remove the old patch before applying a new one. Never apply more than 1 patch at a time, unless your doctor tells you to.

If you often forget to change patches, it may help to set an alarm to remind you. You could also ask your pharmacist for advice on other ways to help you remember to take your medicines.

It's important not to take or use more than your prescribed dose, even if you think it's not enough to relieve your pain. Speak to your doctor first if you think you need a different dose.

Too much buprenorphine can be dangerous. However, the amount that can lead to an overdose varies from person to person.

If you've taken too much you may feel very sleepy, sick or dizzy. You may also find it difficult to breathe. In serious cases you can become unconscious and may need emergency treatment in hospital.

• you've taken more than your prescribed dose of buprenorphine and you have difficulty breathing, start to lose consciousness or feel sleepy, sick or dizzy
• you or someone else swallows a buprenorphine patch

• you've taken more than your prescribed dose of buprenorphine, even if you do not have symptoms

Go to 111.nhs.uk or call 111 . Call 111 if you're asking about a child under the age of 5 years.

If you need to go to A&E, do not drive. Ask someone to drive you or call 999 and ask for an ambulance.

Bring the buprenorphine packet or leaflet inside it, any remaining medicine, and any other medicines you take.

If you need to take or use buprenorphine for a long time your body can become used to it.

This is not usually a problem. However, you could get withdrawal symptoms if you stop using it suddenly.

If you want to stop using buprenorphine, talk to your doctor first. Your dose can be reduced gradually so you're less likely to get withdrawal symptoms.

If you stop using buprenorphine suddenly it can make you:

• feel agitated
• feel anxious
• shaky
• sweat a lot

If you've been taking or using buprenorphine for more than a few weeks, do not stop without speaking to your pharmacist or doctor first.

These common side effects of buprenorphine happen in more than 1 in 100 people. There are things you can do to help cope with them:

Get more fibre into your diet such as fresh fruit, vegetables and cereals, and drink plenty of water. If you can, it may also help to do some gentle exercise.

Speak to your doctor or pharmacist about a laxative medicine to prevent or treat constipation caused by buprenorphine. Your doctor may prescribe you a laxative alongside your buprenorphine to prevent constipation. You can also speak to your pharmacist about buying a laxative from your local pharmacy.

This side effect should normally wear off after a few days. Talk to your doctor if it carries on for longer.

If you're being sick, try small frequent sips of water to avoid dehydration. Signs of dehydration include peeing less than usual or having dark, strong-smelling pee.

If you take the combined contraceptive pill or progestogen-only pill and you're being sick, your contraception may not protect you from pregnancy. Check the pill packet for advice.

These side effects should wear off within a week or 2 as your body gets used to buprenorphine. Talk to your doctor if they carry on for longer.

Do not drink alcohol as it will make these side effects worse. Do not drive, ride a bike or use tools or machinery.

Stop what you're doing and sit or lie down until you feel better. Do not drink alcohol as it will make these side effects worse.

If the feeling does not go away, do not take any more medicine and speak to a pharmacist or your doctor.

Do not drive, ride a bike or use tools or machinery.

Talk to your doctor if you feel confused. Your dose may need to be changed.

Make sure you rest and drink plenty of fluids. Do not drink alcohol as this can make headaches worse. Ask your pharmacist to recommend a painkiller.

Headaches should usually go away after the first week of using buprenorphine. Talk to your doctor if they last longer than a week or are severe.

Try to rest and relax. It can help to eat and drink slowly and have smaller and more frequent meals.

Putting a heat pad or covered hot water bottle on your stomach may also help. But do not do this if it would be near to your buprenorphine patch. Patches should not be exposed to heat.

If you're in a lot of pain, speak to your pharmacist or doctor. 

It may help to take an antihistamine, which you can buy from a pharmacy. However, some types of antihistamine may not be suitable to take with buprenorphine. Check with the pharmacist to see what type is suitable for you.

If symptoms do not go away or get worse talk to your doctor as you may need to try a different painkiller.

Speak to a doctor or pharmacist if the advice on how to cope does not help and a side effect is still bothering you or does not go away.

Serious side effects happen in less than 1 in 100 people.

Call a doctor or call 111 now (and remove a patch if you're wearing one) if:

• your muscles feel stiff for no obvious reason
• you feel dizzy, tired or have low energy – these could be a sign of low blood pressure

• you have difficulty breathing or have short shallow breathing
• you've had a fit or seizure

In rare cases, it's possible to have a serious allergic reaction (anaphylaxis) to buprenorphine.

Call 999 now if:

• your lips, mouth, throat or tongue suddenly become swollen
• you're breathing very fast or struggling to breathe (you may become very wheezy or feel like you're choking or gasping for air)
• your throat feels tight or you're struggling to swallow
• your skin, tongue or lips turn blue, grey or pale (if you have black or brown skin, this may be easier to see on the palms of your hands or soles of your feet)
• you suddenly become very confused, drowsy or dizzy
• someone faints and cannot be woken up
• a child is limp, floppy or not responding like they normally do (their head may fall to the side, backwards or forwards, or they may find it difficult to lift their head or focus on your face)

You or the person who's unwell may also have a rash that's swollen, raised, itchy, blistered or peeling.

These can be signs of a serious allergic reaction and may need immediate treatment in hospital.

Some people with conditions that need long-term pain relief may need to take buprenorphine for a long time.

If you need to take it for a long time your body can become used to it (known as tolerance). That means you need higher doses to control your pain over time.

Some people can become more sensitive to pain (hyperalgesia). If this happens, your doctor will reduce your dose gradually to help these symptoms.

It's possible to become addicted to buprenorphine. For this reason, your dose will be reviewed to make sure you're only having the amount you need to control your pain.

Your treatment plan may include details of how and when you'll stop buprenorphine

If you're having treatment for cancer pain or other severe pain, your pain control will be carefully monitored. Speak to your doctor if you're worried about tolerance, hyperalgesia or becoming addicted.

These are not all the side effects of buprenorphine. For a full list see the leaflet inside your medicines packet.

Buprenorphine may occasionally be used for pain that is severe or difficult to treat during pregnancy.

If you take buprenorphine towards the end of pregnancy your baby might have withdrawal symptoms, such as drowsiness, after they're born. Your baby may need extra time in hospital for observation.

It's important to treat pain in pregnancy. For some pregnant women with pain that's difficult to treat, buprenorphine might be the best option. Your doctor is the best person to help you decide what's right for you and your baby.

You can use buprenorphine if you're breastfeeding.

Only very small amounts of buprenorphine pass into breast milk, but there's still a small risk that it may cause side effects in your baby. Your doctor may recommend different painkillers first.

If you do take buprenorphine while breastfeeding, it's best to take it in low doses and only for a short time. This reduces the risk of your baby getting side effects.

It's also important not to stop breastfeeding suddenly so your baby does not get withdrawal symptoms.

Talk to your doctor, pharmacist, health visitor or midwife as soon as possible if you have any concerns about your baby, including if you notice your baby:

• is not feeding as well as usual
• has constipation
• seems unusually pale

• your baby is unusually sleepy
• your baby has breathing problems

However, these effects are very rare.

If you need to go to A&E, take the buprenorphine packet or leaflet inside it, plus any remaining medicine, with you.

There's no evidence that buprenorphine affects fertility in either men or women.

Speak to a pharmacist or your doctor if you're trying to get pregnant. They may want to review your treatment.

Tell your doctor if you're:

• trying to get pregnant
• pregnant
• breastfeeding

There are some medicines that may affect how buprenorphine works.

Tell your doctor if you're taking any medicines:

• to help you sleep
• for mental health problems including depression, or to reduce stress or anxiety
• for high blood pressure
• to help stop you feeling or being sick
• to treat symptoms of an allergy
• for any infection (including HIV)
• to control fits or seizures

It's safe to use buprenorphine with paracetamol, ibuprofen or aspirin.

Do not take any painkillers containing codeine, such as co-codamol or combined ibuprofen and codeine (brand names Nurofen Plus or Solpadeine) when you're using buprenorphine. You'll be more likely to get side effects if you take any of these while using buprenorphine.

There's not enough information to say that complementary medicines and herbal remedies are safe to take with buprenorphine.

They're not tested in the same way as pharmacy and prescription medicines. They're generally not tested for the effect they have on other medicines.

Tell your doctor or pharmacist if you're taking any other medicines, including herbal remedies, vitamins or supplements.