Transcript Adam Gordon's PPT
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
Allowed “Qualified” physicians to treat opioid dependence outside methadone facilities 1.
Addiction certification from approved organization, or 2.
3.
Physician in clinical trial of qualifying medication, or 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
Opioid Treatment: Changing Approach Methadone Clinic
• Criteria: Withdrawal 12 months use • Dose regulated • Age > 18 • Limited take homes • Services “required”
Office-Based treatments
• Criteria: DSM IV No time criteria • MD sets dose • Age > 16 • Take homes (30 days) • Services must be “available”
Gordon, Counterdetails, 2006
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
Buprenorphine’s Properties: Partial Agonist 100 90 Full Agonist (Methadone) 80 70 “Activity” or “Response” 60 50 40 Partial Agonist (Buprenorphine) 30 20 10 Antagonist (Naloxone) 0 -10 -9 -8 -7 -6 -5 -4 Log DOSE Gordon, Counterdetails 2006
Buprenorphine Properties: High Affinity Gordon, Counterdetails, 2006
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)
Diversion potential: Buprenorphine/Subutex PO IV SL
Route Buprenorphine Absorbed?
Naloxone Absorbed?
Outcome
Incorrect Oral NO NO
(No Action) Incorrect IV (diversion) YES Correct Sublingual YES YES!!!
NO !
Pt:
MD:
!
Gordon, Counterdetails, 2006
Rationale for Naloxone+Buprenorphine (Suboxone) PO IV SL
Route Buprenorphine Absorbed?
Naloxone Absorbed?
Outcome
Incorrect Oral NO NO
(No Action) Incorrect IV (diversion) YES YES!!!
(withdrawal) Correct Sublingual YES NO !
!
Gordon, Counterdetails, 2006
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
Buprenorphine: Treatment Retention
100 80 60 40 73% HI METH 58% BUP 53% LAAM 20 20% LO METH 0 1 2 3 4 5 6 7 8 9 1011121314151617 Study Week
Johnson R, NEJM 2000
Buprenorphine: “Clean” Urines
100 80 All Subjects 60 49% 40% LAAM BUP HI METH 40 39% LO METH 20 19% 0 1 3 5 7 9 11 Study Week 13 15 17
Johnson R, NEJM 2000
Buprenorphine: Retention and Mortality
0 deaths 20 15 10 4 deaths 5 Bup 6 day detox Bup Maintenance 0 0 50 100 150 200 250 All Patients received group CBT Relapse Prevention, Weekly Individual Counseling, 3x Weekly Urine Screens. n=20 per group Treatment duration (days) 300 350
Kakko J, Lancet 2003
Buprenorphine: Reduces Other Drug Use Fudala, NEJM 2003
Opioid Dependence Treatment in Primary Care At 24 weeks, 59% remained in treatment Stein, JGIM 2005
Buprenorphine is not diverted OXYCODONE METHADONE BUPRENORPHINE Cicero, NEJM 2005
McLeod, SAMHSA 2005
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