buprenorphine: introduction (and induction)
DESCRIPTION
Buprenorphine: Introduction (and Induction). Adam J. Gordon, MD, MPH, FACP, FASAM University of Pittsburgh School of Medicine VA Pittsburgh Healthcare System [email protected]. Drug Abuse Treatment Act (DATA) of 2000. - PowerPoint PPT PresentationTRANSCRIPT
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Buprenorphine: Introduction (and Induction)
Adam J. Gordon, MD, MPH, FACP, FASAMUniversity of Pittsburgh School of Medicine
VA Pittsburgh Healthcare [email protected]
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Drug Abuse Treatment Act (DATA) of 2000
• Allowed “Qualified” physicians to treat opioid dependence outside methadone facilities1. Addiction certification from approved organization, or2. Physician in clinical trial of qualifying medication, or3. Complete 8-hour course from approved organization
• DEA issues (free) to qualifying physicians a new DEA number to use medication for opioid dependence
• As of today, only one medication formulation is approved for this use
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Opioid Treatment: Changing Approach
Methadone Clinic Office-Based treatments• Criteria:
Withdrawal12 months use
• Criteria:DSM IVNo time criteria
• Dose regulated • MD sets dose
• Age > 18 • Age > 16
• Limited take homes • Take homes (30 days)
• Services “required” • Services must be “available”
Gordon, Counterdetails, 2006
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Buprenorphine Properties• Partial-agonist
• Less reinforcing than a full agonist-milder effects• Easier withdrawal• Safety – overdose ceiling effect
• High affinity to the opiate receptor• Long duration of action (24-72hr)• Strong safety profile
• Little respiratory depression• Little overdose potential
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-10 -9 -8 -7 -6 -5 -40
10
20
30
40
50
60
70
80
90
100
“Activity” or “Response”
Log DOSE
Full Agonist(Methadone)
Partial Agonist(Buprenorphine)
Antagonist (Naloxone)
Buprenorphine’s Properties:Partial Agonist
Gordon, Counterdetails 2006
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Buprenorphine Properties:High Affinity
Gordon, Counterdetails, 2006
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Buprenorphine Formulations• Formulations and routes
• BUPRENEX IV NOT for Opioid Dependence • Long history within Anesthesiology• History of use as mild analgesic
• SUBUTEX SL - Buprenorphine• 2 mg tablet• 8 mg tablet• Really one indication… (Pregnancy)
• SUBOXONE SL – Buprenorphine/Naloxone• 2mg/0.5mg tablet• 8mg/2mg tablet
• (Buprenorphine Transdermal)• (Buprenorphine Depot Injection)
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Diversion potential: Buprenorphine/Subutex
Incorrect Incorrect CorrectRoute Oral IV (diversion) SublingualBuprenorphine Absorbed? NO YES YESNaloxone Absorbed? NO YES!!! NO !Outcome
(No Action)Pt:
MD: !
PO SLIV
Gordon, Counterdetails, 2006
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Rationale for Naloxone+Buprenorphine(Suboxone)
Incorrect Incorrect CorrectRoute Oral IV (diversion) SublingualBuprenorphine Absorbed? NO YES YESNaloxone Absorbed? NO YES!!! NO !Outcome
(No Action)
(withdrawal)!
PO SLIV
Gordon, Counterdetails, 2006
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Most often heard quote with Buprenorphine
“Doc, I feel normal”
• Treatment in normal medical settings:• Encourages continuity of medical/specialty care• Encourages relationship building with clinicians• Legitimize opioid dependence as a normal, treatable,
chronic illness
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Buprenorphine: Treatment RetentionPe
rcen
t Ret
aine
d
0
20
40
60
80
100
1 2 3 4 5 6 7 8 9 1011121314151617
20% LO METH
58% BUP
73% HI METH
53% LAAM
Study Week
Johnson R, NEJM 2000
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Buprenorphine: “Clean” UrinesM
ean
% N
egat
ive
Study Week
All Subjects
LO METH
BUPHI METH
LAAM
1 3 5 7 9 11 13 15 170
20
40
60
80100
19%
40%
39%
49%
Johnson R, NEJM 2000
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Buprenorphine: Retention and Mortality
All Patients received group CBT Relapse Prevention, Weekly
Individual Counseling, 3x Weekly Urine Screens. n=20 per group
Treatment duration (days)
Remaining in treatment (nr)
0
5
10
15
20
0 50 100 150 200 250 300 350
Bup 6 day detoxBup Maintenance
4 deaths
0 deaths
Kakko J, Lancet 2003
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Buprenorphine: Reduces Other Drug Use
Fudala, NEJM 2003
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Opioid Dependence Treatment in Primary Care
Stein, JGIM 2005
At 24 weeks, 59% remained in treatment
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Buprenorphine is not diverted
Cicero, NEJM 2005
OXYCODONE
METHADONE
BUPRENORPHINE
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McLeod, SAMHSA 2005
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Useful Websites
• Buprenorphine Information: www.buprenorphine.samhsa.gov
• NIAAA Web site: http://www.niaaa.nih.gov/• Medication information: http://www.suboxone.com• Physician Clinical Support System (PCSS)-
National Mentor for Physicians Treating Opiate Dependence. http://www.PCSSmentor.org