Transcript Burns M. Brady, MD, ASAM, FASAM, ABFP, FAAFP A. Dole and Nyswander (1965) – use of methadone to correct a “possible” lesion or.

Burns M. Brady, MD, ASAM, FASAM, ABFP, FAAFP
A.
Dole and Nyswander (1965) – use of
methadone to correct a “possible”
lesion or defect in the endogenous
opioid system with “possible” down
regulation of the opioid receptor
system secondary to long standing
exogenous opioid use and abuse
B.
J Thomas Payte – personal
conversation 10 years ago – there
exists a small number of people who
“apparently” have a non or
dysfunctional endogenous opioid
system
Zweber & Payte (1995)
C.
McLellan 1983
Only 10% to 20% of patients who
discontinue methadone are able to
remain abstinent (size of study and
collateral information, i.e.
resocialization, therapy, and 12-step
support system)
“It is commonly accepted that addictive disorders
are complex phenomena that involve the
interaction of biological, psychosocial, and
cultural variables, all of which need to be
addressed if treatment is to be effective. As a
medical modality based on proper use of opioid
agonist medication, it should be clear that the
medication itself is central to and the foundation
of OMT as a treatment modality. However,
favorable treatment outcomes require that the
medical intervention be integrated with a host of
other therapies and supportive and rehabilitative
services.”
A.
Drug addiction treatment act 2000
(Clinton)
Allows office based prescription of
narcotics for the treatment of
addiction
B.
Buprenorphine cleared FDA (2002) for
treatment of opioid dependence
Opiate partial agonist with strong affinity for the Mu
receptor and minimal activity with the Kappa receptor
There is some antagonist action at other receptors
A.
B.
Suboxone – Narcan (Naloxone) + Buprenorphine
1:4 ratio
Subutex – Buprenorphine
First Buprenorphine treatment program was
founded by Dr. David McDowell at Columbia
University (88% successful by this statistic)
Reported in the literature 2004
C.
A special federal waiver (which can
be obtained following an 8 hour
course completion) is required to
treat patients with an opiate addiction.
Currently each physician can see 100
opiate addicts in his/her practice. No
special education requirements in
addiction medicine are mandated. (One
year in prescribing Buprenorphine
and/or use of groups)
D.
Buprenorphine has been claimed and
is generally viewed to have less
euphoric effects than other opiates
Subsequent studies have proved this
to be untrue or inconsistent.
E.
Wikipedia reference – Inpatient Rehab
“The treatment phase begins once the patient is
stabilized and receives medical clearance. This
portion of treatment comprises multiple
therapy sessions, which include both group and
individual counseling with various chemical
dependency counselors, psychologists,
psychiatrists, social workers, and other
professionals. Additionally, many treatment
centers utilize 12-step facilitation techniques,
embracing the 12-step programs practiced by
such organizations as Alcoholics Anonymous
and Narcotics Anonymous.”
F.
Frequent studies stating the most
frequent use of illicit Buprenorphine is
for detox or maintenance therapy. In
U.S., studies such as this one, which
refutes that, are pending or in process.
In Scandinavian countries, studies
(significant in number and credibility)
are revealing just the opposite “primary
use is recreational”
G.
Buprenorphine behaves differently from other
opioids in that it shows a “ceiling” effect thus
negating respiratory depression. This protects
against death due to the overdose sedating
effect of the respiratory center.
Concurrent use of Buprenorphine and CNS
depressants (alcohol, benzodiazepines,
barbiturates) are now being seen with increased
frequency as a cause of fatal overdose. Again
we have physicians significantly undereducated
in addiction medicine (8 hours in
Buprenorphine pharmacology) deciding what to
do beyond detox, i.e. maintenance or long term
replacement
H.
Multiple studies and anecdotal
information suggests Buprenorphine is
a strong drug of choice for opiate
addicts in or getting out of prison.
Let’s see the results of this study in
two large SAP programs and one large
indigent shelter. Let’s review this
population’s experience from previous
exposure (treatment attempts and
recreational use) to Buprenorphine.
I.
Lloyd Gordon, MD, is Medical Director of COPAC
Alcohol and Drug Treatment Center in Jackson,
Mississippi. Dr. Gordon is both a member and
fellow in the American Society of Addiction
Medicine (ASAM)
COPAC is a highly respected center which began in
the early 1980’s
Dr. Gordon, in his November 2010 alumni letter
from COPAC, has endorsed abstinence treatment
following detox. His data strongly refutes the
efficacy of opiate maintenance therapy.
He profiles the very limited number of patients for
whom he has found this effective. He reports the
very large number of patients for whom it is not.
As we try to make some sense out of this avalanche of
Buprenorphine information as the new herald solution for
opiate treatment, let’s look at a direct quote from Wikipedia.
“Nearly half a century after Doctors Dole and Nyswander
pioneered methadone replacement treatment for opioid
dependence, the medical treatment of narcotics addiction
remains controversial. To call it controversial – since the
discovery of stereo-specific opiate receptor sites in the brain,
spinal cord, and GI tract which modulate perception of pain,
temperature, via endorphine (endogenous morphine) and
enkephalins has conclusively proven the metabolic nature of
opiod addiction – is to ignore science.”
The science is correct – the insight into treatment for addiction
is appalling.
This quotation reveals the myopia and
ignorance of much of the scientific
community about the addict. This includes
ASAM and the UVA chairman of the psychiatry
department, etc.
This coupled with the fear, long term abuse by
health care professionals, and a growing
population ignorant in the spiritual principles
of recovery does not bode well for future
outcomes of alcohol and drug addiction
treatment – especially the opiate addict.
In the Immanuel Movement of 1900-1910 in
Boston, a basic premise was established.
This disease of drug addiction and alcohol abuse is
A) Physical
B) Mental
C) Emotional
It’s solution is spiritual
Agreed – we have developed the SSRI, atypical
antipsychotics, anticonvulsants and other
antidepressants – in doing this we have gradually
thrown out the baby with the bath water
The last assault of this magnitude to the
recovering population was the introduction of
Benzodiazepines as the treatment for
alcoholism. (We are still paying for this
“evidence based” and “receptor justified”
position as we treat addictions.)
The long-term (10-15-20 years) follow up of
this scientific experiment of Buprenorphine
and opiate replacement does not exist (in
spite of quotes to the contrary).
The recovering community begged the
scientific community to become
knowledgeable about this disease. Today the
information is legion (look at our textbook).
Evidence based research is essential.
What we must remember is that addiction is
not less than science but is so much more.
As I was taught so appropriately and
profoundly:
“To discern the correct diagnosis and conclude
the best treatment – listen to the patient.”