butrans vs nucynta

[bedrock]

What medical criteria do you all use for for prescribing butrans vs Nucynta?

For this exercise lets compared butrans to nucynta ER as insurance seems to favor ER over IR, and the ER is a better comparison to butrans as they both provide long term coverage.

And how often do you switch between them? meaning for patients that need around the clock coverage, but don't respond to one or the other, initially. Both are clearly safer long term than standard opioids, which most of us avoid when possible for obvious reasons.

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[lobelsteve]

C-II vs C-III, both safer than conventional opiates.

 

[bedrock]

C-II vs C-III, both safer than conventional opiates.

They both should be C III

My question for the group, is

1-in which clinical situations do you start with one vs the other?
2-How often if they fail option one, do you trial them on the other, or do you just give up on any pseudo-opioid at that point?

 

[Agast]

I like Belbuca/butrans for pain that has a myofascial component and Nucynta for neuropathic. I also like Belbuca/butrans for people with digestive issues, gastric sleeve/gastric bypass absorption problems

 

[TIVAndy]

our town pharmacies don't carry nucynta.. i wish they do

 

[painfree23]

Im sure insurance coverage is the main reason

 

[MitchLevi]

I've tried Nucynta on probably 3-4 pts in the last 6 weeks or so, and none of them are currently on it today bc insurance simply will not allow it. I don't understand why.

 

[paindoctor2014]

I like both medications. Neuropathic pain and crps specifically for nucynta.

Butrans seems to be much easier to get insurance coverage

 

[bedrock]

If patient with mostly neuropathic pain, failed several neuropathic meds, and has decent insurance I would start with nucynta

If patient with OA/myofascial pain and/or GI absorption issues, I'd start with butrans

If patient with bad insurance, I start with butrans, because butrans is generic and as I outlined in a post on the bup or bust thread, (with free discount cards/codes), anyone can get butrans for $50-70 monthly out of pocket cost. Nucynta is not generic and so less of an option if no/poor insurance coverage.


Any other thoughts on when the rest of you start with one, or switch to the other?

 

[deleted131481]

Maybe I will try nucynta again, haven't in a while because of insurance issues. I would try it for neuropathic pain that failed neuropathic meds and tramadol.

Had a denial/peer to peer request for Butrans - would only approve brand name and not generic, it was very bizarre. I didn't realize that that was the issue til I gotten the phone, but I said fine by me. I don't think I've ever written for a brand name only medication.

Between Butrans or Belbuca I will often give the patient a chance to choose. Some strongly prefer or have an aversion to patches.

Those that I'm transitioning off other opioids tend to prefer Belbuca because they have more control over it (other than those that don't like either and just go elsewhere).

 

[GoBeers]

at this point my opioid practice is basically:

if patient with neuropathic pain, post arthroplasty pain, post traumatic pain, post surgical pain, rheumatologic pain and abdominal pain, i'll do tramadol to buprenorphine (whichever is covered by insurance).

if patient with musculoskeletal pain (not fibro), depending on age and pathology (ie. myofascial 30 year old vs 50-80yo arthritic) then tramadol, maybe norco (really try to keep it at BID as to "avoid" inevitable development of tolerance. if trouble with tolerance , then i'll consider buprenorphine.

 

[Ducttape]

for most patients, using any opioid means they have failed all other options first.


at that point, for palliative pain management, i usually start with tramadol, then transition to nucynta for neuropathic pain, butrans or low dose vicodin for nociceptive pain.

(no opioids for "myofascial pain" per se, but okay for end stage nociceptive pain such as severe OA)

 

[GoBeers]

do any of you see middle age post-harrington rod scoliosis patients? seem to be getting a few of these referrals. not sure what to make of them other then mechanical dysfunction and maybe adjacent level diseases.

 

[Crybaby]

I like nucynta but I feel like it is way overvalued on morphine equivalents. So I typically pass.

 

[painfree23]

Ever tried to stim em?

do any of you see middle age post-harrington rod scoliosis patients? seem to be getting a few of these referrals. not sure what to make of them other then mechanical dysfunction and maybe adjacent level diseases.

 

[MitchLevi]

Sagittal balance issues common in that population. I see them occasionally.

 

[GoBeers]

Sagittal balance issues common in that population. I see them occasionally.

what is your approach? nsaids and PT? surgeons probably would love to do more fusing i'm sure...

 

[MitchLevi]

what is your approach? nsaids and PT? surgeons probably would love to do more fusing i'm sure...

Surgeons don't want to touch these actually, especially if you're pushing T10 or higher.

My approach is nothing TBH. There's nothing you can do but give meds and occasional PT.

 

[TIVAndy]

If patient with mostly neuropathic pain, failed several neuropathic meds, and has decent insurance I would start with nucynta

If patient with OA/myofascial pain and/or GI absorption issues, I'd start with butrans

If patient with bad insurance, I start with butrans, because butrans is generic and as I outlined in a post on the bup or bust thread, (with free discount cards/codes), anyone can get butrans for $50-70 monthly out of pocket cost. Nucynta is not generic and so less of an option if no/poor insurance coverage.


Any other thoughts on when the rest of you start with one, or switch to the other?

a lot of patients will complain about that 50-70 dollars per month

 

[fathead88]

a lot of patients will complain about that 50-70 dollars per month

But then spend $200/month on cigarettes

 

[paindoctor2014]

I like nucynta but I feel like it is way overvalued on morphine equivalents. So I typically pass.

Agreed on the mme

 

[bedrock]

a lot of patients will complain about that 50-70 dollars per month

And will get zero sympathy from me. A take it or leave it situation which is what I tell them in the room.