Transcript Buprenorphine

Buprenorphine/Naloxone:
Office-Based Opioid Dependence
Treatment
November 29, 2013
Curtis Handford MD CCFP MHSc
Dale Wiebe MD CCFP
Addictions Program
+ Faculty/Presenter Disclosure
•
•
•
Faculty: Curtis Handford/Dale Wiebe
Program: 51st Annual Scientific
Assembly
Relationships with commercial
interests:
–
None
2
+ Disclosure of Commercial Support
•
No commercial support of this program
•
Potential for conflict(s) of interest:
None
3
+ Mitigating Potential Bias
•
N/A
4
+ Acknowledgements
“Psychopharmacology of Opioids” Planning Group:
DR. BERNARD LeFOLL MD, PhD, CCFP
University of Toronto/CAMH
DR. PETER SELBY MBBS, CCFP, FCFP, dip ABAM –
University of Toronto/CAMH
DR. MARILYN HERIE PHD, MSW, RSW
University of Toronto/CAMH
ROSA DRAGONETTI MA, CAMH
WAYNE SKINNER MSW, University of Toronto/CAMH
ANDREA TSANOS MA, CAMH
CAMH Education Services:
MS. GALIT KADIN
MS. ANNE SIMON
5
Objectives
By the end of the workshop you will be able to:
 List
the benefits and describe pharmacology of
buprenorphine/naloxone (Suboxone)
 Demonstrate
the key elements of:
Diagnosis
 Preparation
 Induction
 Maintenance

+
 Cite
the CAMH guideline (CPG) recommendations
for the use of buprenorphine/naloxone.
6
+ Agenda
130-140: Welcome and Introductions
140-200: Diagnosis
200-220: “Mary” video #1 and discussion
220-245: Treatment options and “Mary” video #2
245-315: Preparation and Induction
315-330: Break
330-400: “Darrell/Nancy” Induction Video and discussion
400-420: Maintenance/Take homes/Urine Tox
420-450: “Darrell/Nancy” take-home doses and discussion
450-500: Wrap up and evaluations
7
+
Treatment Setting
8
+
Buprenorphine in Primary Care
 France’s
buprenorphine maintenance has largely
been prescribed by primary care physicians.
 1994-1999,
access to opioid dependence treatment
increased (bupe 80%, meth 20%) and overdose
deaths decreased significantly (79%).
Auriacombe et al. The American J on Addictions 2004;13:S17-28
 Several
studies demonstrate that buprenorphine can
be used as effectively and safely in primary care
when compared to specialty clinics.
Gibson et al. Med J Australia 2003;179:38-4
O’Conner et. al. Am J Med 1998;105:100-105
9
+
CPG Recommendation 2
 Buprenorphine/naloxone
maintenance
treatment can be prescribed to patients in
either a primary care setting or in a specialized
addiction treatment setting. [I, A].
 Intro
p.12: “Advisable for a physician or pharmacist
with no experience in opioid maintenance
treatment to complete a formal program
(examples: Appendix I)
Drug monograph: Prescribers are to complete an
“accredited Suboxone education program”
 CPSO: “buprenorphine prescribing course” + observe

10
+ Diagnosis
11
+ CPG Recommendation 3
•Prior
to initiating maintenance opioid
agonist treatment the patient should meet
the diagnostic criteria for opioid
dependence. [III, A]
•Hard
to interpret these DSM criteria in CNCP.
Can be a challenging diagnosis to make in the
chronic pain population.
(Heit H and Gourlay D., 2009)
•Canadian
Opioid Guidelines are a resource to
assist
http://nationalpaincentre.mcmaster.ca/opioid/documents.html
12
+
Case 1: Background
 Your
patient of 5 years, John Doe,
25, arrives for an appt. one day and
informs you he needs help for his
addiction
 He
has been buying MSContin® off
the street for 18 months, “peeling”
and injecting them. He now uses
4x100 mg tabs per day
 Flu-like
symptoms if goes 12 hrs
without
13
+
Case 1: Background
 Spends
all day worrying about how
he is going to be able to get the
money to pay for the pills
 Lost
girlfriend, job, house
 Has
tried to control his use, but he
can’t seem to reduce his dose at all
14
+
DSM-IV
 Tolerance:
Yes
 Withdrawal:
Yes
 Time
Yes
Spent:
 Unsuccessful Attempts
 Given
 Used
 Use
to D/C: Yes
up activities: ?
more than intended: ?
despite consequences: Yes
15
+
Case 1: The Issue
 Diagnosis?
 Opioid
dependence
 Plan?
 Withdrawal
mgmt and intensive
psychosocial treatment
 Buprenorphine/Naloxone
 Methadone
16
+
Case 2: Background
 Your
patient, Jane Frank, 53, has
been prescribed codeine Contin®
from you for the past 5 years to treat
severe hip pain second to
osteoarthritis
 Her
pain scales are usually 3/10.
She is able to work as receptionist
and garden/golf. No previous
evidence of misuse of prescription
17
+
Case 2: Background
 Jane
walks into the office and
anxiously informs you that she had
got stuck out of town for a day and
ran out of her codeine.
 In
that 24-hr period, she started to
develop sneezing, generalized
pain, nausea, sweats. This
resolved after resuming codeine.
 She
is frightened and wants to
know if she is “addicted” to her
codeine.
18
+
DSM-IV
 Tolerance:
Yes
 Withdrawal:
Yes
 Time
No
Spent:
 Unsuccessful Attempts
 Given
 Used
 Use
to D/C: No
up activities: No
more than intended: No
despite consequences: No
19
+
Case 2: The Issue
 Diagnosis?
 Physical
 What
dependence
do you advise her?
 No
evidence of opioid dependence
 Physical dependence is an expected
physiologic phenomenon. Does not equal
addiction
 Next
steps?
 Carry
on
 Perhaps try a slow taper if patient really
concerned
20
+ Diagnosis: “Mary”
Mary Video 2A:
Q: Which criteria of the criteria listed in the DSM-IV have you identified in
Mary’s history?
21
+
Mary: DSM-IV
 Tolerance:
 Withdrawal:
 Time
Spent:
 Unsuccessful Attempts
 Given
 Used
 Use
to D/C:
up activities:
more than intended:
despite consequences:
22
+
Case 3: Mary
 Diagnosis?
 What
 Next
do you advise her?
steps?
23
+ Prescribing
Practices:
 Trial
of Opioid Therapy in properly selected
patients
 Check
the “5 A’s” at every follow up visit (6-9
wks)7:
 Analgesic effectiveness (pain scales)
 Adverse Effects
 Ability to function
 Aberrant/Abuse behaviors (including
substances)
 Affect
 If
pain & function consistently improved at
reasonable dose, can carry on without need for
consultation.
24
+
Prescribing: Aberrant Behavior
 High-risk
abuse behaviors23,40:
Many unsanctioned dose escalations
 Frequent lost prescriptions
 Concurrent abuse of related illicit drugs
 “Borrowing” drugs from others/street
 Injecting (tracks!), forgery, selling, doubledoctoring

25
+
Prescribing: Aberrant Behavior
 Prevalence
among chronic pain
patients: 11.5%
 Illicit
drugs present in 14.5% of UDSs
 No
opioid or non-prescribed opioid in
20.4% of UDSs33
26
+
Prescribing: Aberrant Behavior
 Grounds
for action!
 “Lesser”
behaviors should lead to
more “structured opioid therapy
(SOT)”

Tightening of the boundaries, UDT, ?addiction medicine
referral
 Watch

for “pseudoaddiction”!
Pseudoaddiction will ameliorate with SOT
27
+
Diagnosing Opioid Dependence

Tolerance, withdrawal in and of themselves do not
equal “addiction”

Acquiring significant amounts of opioids from
other sources (other MDs, OTC, street)

Injecting or insufflating prescribed opioids

Failure to stabilize aberrant behavior with SOT


If appropriate
DSM IV-TR versus DSM V update
 OAT for moderate to severe?
28
+
DSM IV-TR
Dependence

Tolerance

Withdrawal

Time Spent

Unsuccessful attempts to
D/C
vs.

Given up activities

Used more than intended

Use despite consequences
Abuse

Failure to fulfill major
role obligations

Use in hazardous
situations

Legal problems

Social or interpersonal
problems
+
DSM V
Substance Use Disorder

Tolerance (not counted if prescribed)

Withdrawal (not counted if prescribed)

Used more than intended

Cravings

Unsuccessful attempts to D/C

Time Spent

Given up activities

Use despite consequences

Failure to fulfill major role obligations

Use in hazardous situations

Social or interpersonal problems

Mild
 2 to 3 criteria

Moderate
 4 to 6 criteria

Severe
 7 to 11 criteria
+ Opioid Dependence Treatment
Options
31
+ Withdrawal
Management
(“Detox”)
Evidence
suggests that OAT outcomes superior
to detox
Can be hazardous on discharge due to loss of
tolerance
Most of OAT evidence from IV heroin users
Reasonable, with informed consent, for some
patients to attempt detoxification:
Patient
preference
Exclusive
Young
PO opioid dependence
age
Brief
duration of dependence
Solid
social supports
32
+
Opioid Agonist Treatment [OAT]
 Observational
studies demonstrate reduced
mortality for individuals on OAT compared to
those off OAT.
(Gronbladh L et. al., 1990)
(Caplehorn JRM et al., 1994)
 Reduced
risky behaviour and decreased HIV
seroconversion rates
(Gowing et. al., 2008)
(Metzger et al., 1993)
33
+
Opioid Agonist Treatment
 Methadone
and buprenorphine
 Meta-analyses
for both drugs confirm superiority to
placebo in terms of retention in treatment and
reduced illicit opioid use
 Flex
dose methadone appears marginally better in
terms of treatment retention (RR 0.85, 0.73-0.98).
 Equivalent
with respect to reducing illicit opioid use.
(Mattick et. al., 2008)
?
Old evidence generalizable to oral prescription
opioid dependent pts
34
+ Buprenorphine: Safety
French
population-level data 1994-1998 suggests
that there is 3x less mortality due to buprenorphine
than due to methadone. “46 rather than 288 deaths”.
Auriacombe
et al. JAMA 2001;285(1):45
Post-mortem
studies also suggest lower rate of
overdose deaths involving buprenorphine compared
to methadone.
Pirnay
et al. Addiction 2004;99:978-988
Soyka
et al. Pharmacopsychiatry 2006;39:85-87
Gibson
et al. Drug and Alcohol Review 2007;26:405410 (?”underestimate of bupe deaths”)
More
OD symptoms with methadone than bupe
Nielson
2007 and Nielson 2008
35
+ Buprenorphine: Safety
Bupe
implicated in some OD deaths
Almost exclusively (116/117) in combo with
other sedating substances.
Kintz
et al. Forensic Science International 2001;121:65-
69.
7/43
bupe-alone deaths in UK 1980-2002
Schifano
et al. Hum Psychopharmacol Clin Exp
2005;20:343-348
No
difference in mortality b/w methadone
and bupe gps
(Ling
1996, Gibson 2008, Soyka & Apelt 2006*)
Bupe
more non-fatal heroin OD’s than
methadone (P=0.08)
DiGiusto 2004
36
+ Pharmacology of buprenorphine
37
+
Unique pharmacological properties
 High
affinity for opioid receptor (i.e. binds tightly),
thus blocking the effect of other opioids.
 Less
risk of overdose and respiratory depression
because it is a partial-agonist.
 Long
half-life, thus allowing less-than-daily
dispensing and possibly easier withdrawal.
(Gowing L, Ali R, White J. 2006).
38
+
Pharmacology: Safety
Mu receptor –

analgesia, respiratory
depression, pupillary
constriction, ↓bowel mobility,
sedation
Kappa receptor – analgesia, dysphoria,
diuresis, ?addiction
Mu receptor partial
agonist (“turns partly on”)

Ceiling effect for opioid
agonist properties
(Walsh SL et al. 1994)
Full Agonist
e.g. morphine
 Kappa
receptor
antagonist (“turns off”)


Threshold for Fatal
Respiratory Depression
Could be what offsets the
respiratory depression effect
at higher doses
May account for decreased
dysphoria observed in some
studies
(Johnson et al, 2003)
Opioid
Effect
Partial Agonist
Dose of Opioid
39
+
Route of Administration &
Pharmacokinetics

Available in Canada as sublingual tablet, takes a few minutes
to dissolve. Film may be coming soon.

Rapid absorption by buccal mucosa, then slowly released into
bloodstream (45 min-1.5 hr)

Peak plasma concentration in 1-4 hrs

Very low oral bioavailability due to first pass effect

Can be abused intravenously (reason for nlx) or intra-nasally

(Chiang CN et. al., 2003. Walsh SLW, et. al., 2003)
40
+
CPG Recommendation 10
 Policy
makers should be aware that in
countries where buprenorphine is equally
available as methadone, buprenorphine has a
lower attributable death rate than methadone.
[II-3, A]
41
CPG Recommendation 1
 Once
a patient is diagnosed with opioid
dependence and is deemed appropriate for
opioid agonist treatment, prescribers are
encouraged to consider prescribing either
buprenorphine/naloxone or methadone in order
to increase retention in treatment and decrease
opioid misuse. [I, A]
+
42
CPG Recommendation 4
 The
decision to initiate opioid agonist therapy
with either buprenorphine/naloxone or
methadone maintenance should be guided by
the individual clinical circumstances and the
patient’s preferences. [III, I]
+
43
CPG Recommendation 12
Buprenorphine/Naloxone may be preferred over
methadone if…




+


C/I to methadone: allergy/QT risks (Level I)
Hx of sexual S/E or oversedation on methadone (Level II)
Increased risk of opioid toxicity (age, PMHx, BZ, meds (Level
II))
Good prognostic factors (age, social, duration)
Past success with buprenorphine
Methadone unavailable in timely manner
44
Recommendation 13
Methadone may be preferred over
buprenorphine/naloxone




+




Allergy to buprenorphine
Pregnancy (buprenorphine/naloxone specifically)
If induction withdrawal dangerous
Hx injecting buprenorphine
Prev inability to stabilize on buprenorphine
Prev success with methadone
Severe dry mouth
No reliable way to pay
45
+ Treatment Options: “Mary”
Mary 2B:
Q: Now that Mary expressed her interest in maintenance treatment with a
long-acting opioid, which medication do you think may be better for Mary? Is
there a specific reason to choose one over the other?
46
+
Using Buprenorphine/naloxone
47
+
CPG Recommendation 6
 Prior
to initiation of buprenorphine/naloxone
treatment, the patient must provide informed
consent and there must be physician
documentation that the patient has been
informed of the physical dependence on the
medication and possible long-term nature of the
maintenance treatment. [III A]
48
+
Buprenorphine-Preparation
 Diagnosis
 Urine
of opioid dependence
Drug Test (UDT) positive for opioids (Sup 4)
 Contraindications?
 Informed



consent
Treatment options
Risks and benefits
Clarify goals and expectations
 Establish
coverage
 Consider
written treatment agreement (Appendix J)
49
+
Bup/Nlx Contraindications
 Pregnancy
(buprenorphine/naloxone specifically)
 Allergy
 Severe
 Acute
liver dysfunction
severe respiratory illness
 Decreased
 Paralytic
 Inability
level of consciousness
ileus
to provide informed consent
 Possibly
elevated transaminases beyond 3-5 times
ULN
50
+
Preparation
 Investigations:



βHCG
Liver enzymes/LFTs
HIV/Hepatitis testing
 Instructions



for induction day:
Present in withdrawal
D/C IR opioids 12+ hrs, SR opioids 24+ hrs
Do not drive
51
+ Formulary coverage
As of October 30, 2012, Suboxone is
Limited Use in Ontario:
LU code 437:
Failed methadone
Intolerance
Contraindication (ie QT, allergy)
Higher risk for opioid toxicity
BZ, alcohol, p450 inhibitors, elderly, lower
tolerance
LU code 438: methadone
maintenance program is not available or
accessible >3 mos
52
Induction
+
53
CPG Recommendation 5
 A physician
should have a structured approach, such
as the one suggested in the clinical considerations,
to initiating buprenorphine/naloxone maintenance
treatment in order to stabilize a patient at their
maintenance dose as rapidly as possible while at the
same time avoiding oversedation or precipitated
withdrawal. [III, A]
+
54
Buprenorphine - Induction
 Patient
must be in moderate opioid withdrawal
before receiving the initial dose of bup/nlx
 Estimated

Short-acting opioids: 6h minimum, 12h preferable



E.g. heroin, oxycodone, hydromorphone, codeine
Longer-acting opioids: 12h minimum, 24h preferable

+
amount of time to wait after last use:
OxyContin® and other slow-release opioids that are chewed or
crushed; longer if swallowed whole
Methadone: 24h minimum, 36h – 3 days preferable
55
Buprenorphine - Induction
 Suggest


2


+

use COWS assessment tool (Appendix K)
If score <13 (mild withdrawal), advisable to wait until next
day or reassess in 2-4 hours
If ≥13, initiate dosing
mg dose if
at higher risk for opioid toxicity
not completely certain the patient is in moderate withdrawal
transferring from methadone
4
mg for patients clearly in withdrawal & at lower
risk for opioid toxicity
COWS=Clinical Opiate Withdrawal Scale
56
Buprenorphine-Induction
 Consider
reassessment at 1hr to assess for
precipitated withdrawal (p/w).
 If
p/w, do not give an additional dose of
buprenorphine/naloxone
 Consider
reassessment at 3hrs to assess need for
additional dose(s).
 Can
+
provide additional 2mg doses on day # 1 (to a
max of 8mg on day 1).

Observed or take-home
 Return
to clinic next 1-3 days for possible dose
increase.
57
Precipitated Withdrawal – What Is It?
 Buprenorphine
preferentially binds to the opioid
receptor, but only partially activates it
 Abrupt
onset of withdrawal symptoms within 1 hour
of taking buprenorphine dose; sxs peak 1.5-3hrs
 May
take up to 12 hours to resolve
+  Management is symptomatic
 Additional
doses will worsen symptoms
58
Precipitated Withdrawal
mu
opioid
receptor
buprenorphine
opioid
Precipitated Withdrawal
dopamine
Intoxication
Significant amount of opioid
bound to receptors
“Volume” on max
Buprenorphine
Binds preferentially to
receptors
“Volume” on medium
Relative to intoxication,
Suboxone® “turns on”
receptors less  patient
feels withdrawal
Induction
+
Withdrawal
Most receptors
unbound
“Volume” on low
Buprenorphine
Binds preferentially to
receptors
“Volume” on medium
59
Relative to withdrawal,
Suboxone® “turns on”
receptors more  patient
feels better
+ Induction: “Darrell”
Q: How would you define the state of Darrell’s withdrawal? How do you
suggest to proceed:
Q: How could this have been prevented?
60
Buprenorphine - Titrating dose
Dose
Maximum recommended daily dose
24 mg
(according to Canadian Product Monograph)
Dose can be increased daily or every 2-3 days
by 2-4 mg
Average maintenance dose range
8-12 mg/day
+
61
Induction
 Faster
induction=better retention
(Compton P et al. 1996)
(Doran C et al. 2005)
 Monitor
for opioid toxicity
 Collateral
 Induction
+
hx valuable if available
is a balance between:
 Buprenorphine’s
dynamics: “Ceiling” effect of
partial agonist
 Buprenorphine’s kinetics: Long half-life of 24-36
hrs
62
Induction
 Maintenance
dose should be reached within a
couple of weeks:
 No opioid withdrawal symptoms for 24hrs
 Reduction in cravings
 No reinforcing effect from opioids
+
63
+ Induction: “Nancy”
Q: What is your interpretation of Nancy’s disclosure? How would you like to
respond?
Q: Based on the information Nancy has thus far provided, will you increase her
bup/nlx dose? By how much? For how many days will you prescribe the new
dose?
Q: Would you increase the dose at this point? How much?
64
65
66
67
68
+
Take-home doses
69
+
CPG Recommendation 9
 In
making decisions regarding the provision of
take-home doses of buprenorphine/naloxone,
providers should use a clinical risk
stratification strategy (as described in the
clinical considerations) that aims to support
patient autonomy while at the same time
respecting patient and public safety. [III, A]
70
+
Buprenorphine/Nlx - Take-home
doses
 Health


Require buprenorphine be prescribed daily observed for 2
months, except for weekends and holidays (if pharmacy
closed)
No evidence identified supporting this for
buprenorphine/naloxone
 When



Canada & Product Monograph:
deciding about take-home doses assess:
Is it safe for the patient?
Is it safe for the public?
What is the risk of diversion?
71
+
Take-home doses
Early in treatment 3 categories:
Too unstable to have any take-homes,
including weekends and holidays
1.







Recent IV drug use
Recent suicidal ideation
Significant cognitive impairment
Unstable housing
Ongoing opioid use
Other active alcohol or drug dependencies
“Concern NYD”
72
+
Take-home doses
Early in treatment 3 categories:
Appropriate to provide “weekend and holiday”
take-homes:
2.
No recent IV drug use
No recent suicidality
No signifiant cognitive impairment
Stable housing
Achieved abstinence from opioids
No other active alcohol or drug dependencies







No “concern NYD”
73
+
Take-home doses
Early in treatment 3 categories:
Appropriate accelerated take-home doses
beyond “weekends and holidays” within the first
2 months:
3.
Clinical stability beyond category 2:



No significant psychiatric co-morbidity

Particularly stable social situation
Overly restrictive take-home dosing may lead to
treatment drop out due to work conflicts.
74
+
Take-home doses
If providing accelerated take homes:
 Consider

other options first
EOD dosing, pharmacy change
 Discuss
with the patient the risks of these
“accelerated” take-homes
 Monitor
closely to ensure benefit
 Document
carefully
75
+
Take-home doses
 Number
of take-home doses per week increases
gradually
 Suggested
maximum of 6-13 consecutive takehome doses, dispensed between observed doses.
 If
relapse to problematic drug use or compromised
clinical stability:


More frequent visits and UDS
Increased number of witnessed doses
76
+ Take-Home Doses: “Darrell” and
“Nancy”
Q: Are there any circumstance under which you will consider to give takehome doses during the first week of treatment with buprenorphine?
Q: What do you want to do with her bup/nlx treatment?
Q: What do we look for to determine “clinical stability”?
Q: When would you consider re-instituting take home doses?
77
+
Take-home doses: Safety
 Injection



abuse:
Plenty of evidence that buprenorphine monoproduct is
injected (Obadia 2001, Vidal-Trecan 2003).
Much more than methadone (Barrau 2001).
Evidence that bup/nlx is pleasurable to non-dependent users
(Strain 2000, Weinhold 1992)


IV Bup/nlx pleasurable in bup/nlx maintained subjects (Bell 2007)
Case reports of hepatotoxicity if abused IV (Herve 2004)
78
+
Buprenorphine/Naloxone: Injection
 Naloxone
was introduced to deter IV use
 Naloxone:





opioid receptor antagonist
binds opioid receptor, but no intrinsic activity
precipitates withdrawal in clients physically dependent on
opioids
little to no sublingual or oral bioavailability
deterrent only when used IV
(Chiang, NC, 2003.)
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+
Buprenorphine/Naloxone: Injection
But naloxone…
 only
partially blocks opioid
receptor binding
 has
much shorter duration
of action than
buprenorphine

Combo product is abused
despite “deterrent effect”
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+
Missed doses
81
+
Buprenorphine - Missed doses

Missed ≤ 5 days may resume their usual dose

Missed > 5 consecutive days MD should reassess before
restarting

New dose can be titrated upwards by 2-4 mg/day
Usual dose
Number of consecutive days missed
New starting dose
> 8 mg
> 7 days
4 mg
> 8 mg
6-7 days
8 mg
6-8 mg
6 or more days
4 mg
2-4 mg
6 or more days
2-4 mg
Lintzeris et. al. Commonwealth of Australia, 2006
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+
Urine Drug Testing (UDT)
 CPG
Recommendation 8: When monitoring a
patient on buprenorphine/naloxone maintenance,
the physician should adopt a patient–centred
urine drug testing strategy that maximizes
clinical utility while avoiding testing without
indication. [III, I]
Guideline Supplement 4
 OAML March/Aug 2013 Memos (Handouts)
 On-line urine toxicology resource:

http://www.udtmonograph.com/
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84
http://www.udtmonograph.com/
+ Urine toxicology
Enzyme
immunoassay (EIA)
Lab
or point-of-care (PoC)
Quick results
Sensitive, not specific
Mostly classes of drugs
Window 3-5 days most substances
Chromatography
(GC/MS or LC/MS)
Lab
only
Slower results
Specific
Individual substances
Shorter window of detection (1-3 days)
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+ Urine toxicology
Ordering
“Drugs
with Community Labs:
of Abuse Screen”
EIA opioids,
“Broad
cocaine, BZ, barbs, THC
spectrum urine toxicology”
Chromatography
Since
Sep 2013: LC/MS/MS
“Please look for….”
86
87
c/o Gamma Dynacare
88
c/o Gamma Dynacare
+ Urine toxicology
Not
as straightforward as it might seem!
Opiate
EIA
Natural
Opiates (ie morphine)
Semi-synthetic (ie oxycodone)
Synthetic (ie fentanyl)
Cross-reactions
Cut-offs
Supervised
collection/temp. testing
Dilute samples
Call
the lab if unexpected result!
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+
Opioid Maintenance Tapering
 Long
term treatment, so almost always patientdriven.
 Principles


of support during taper:
Frequent clinic visits
Supportive counseling
 Pace
of the taper determined by client except in rare
cases of involuntary discharge.
 Clonidine,
NSAIDs, loperamide as adjuncts near end
of taper.
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+
Buprenorphine Tapering
 Withdrawal
may be less prolonged and severe than
for methadone
 Maybe
 Taper
delayed in onset
slowly (e.g. 2mg per week)
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+
Opioid Maintenance Tapering (cont’d)
 Put



taper on hold or increase dose if:
severe withdrawal symptoms
drug cravings
drug use
 “Detoxification
fear”: client may be fearful of life
without safety net of medication and program
support, especially near end of taper
 Important
to offer support post-taper and facilitate
return to opioid maintenance treatment if relapse
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+
Buprenorphine Overdose
 Signs:
sedation, hypotension, pinpoint pupils,
respiratory depression
 Low risk overdose unless combined with other CNS
depressants
 Medical emergency – need hospital monitoring
 Primary management should be protection of airway
 Naloxone may not be effective

higher doses than usual recommended to increase the
probability that naloxone will preferentially bind opioid
receptor vs. buprenorphine
93
+ Summary
Buprenorphine/naloxone
is an evidence-based
maintenance treatment for opioid dependence
Evidence for efficacy and safety in primary care
settings
Partial mu properties reduces overdose risk
Office-based physicians can:
Diagnose
Induct
Maintain
Take-home doses are contingent on clinical
stability
Urine drug testing is an important aspect of this
work
94
+ Resources
1.
2.
CAMH Bup/Nlx on-line course (early ‘14)
CAMH ODT core course:
Jan 9-Feb 9/14
Feb 15-Mar 15/14
Mar 27-Apr 27/14
3.
Addiction Medicine Service at CAMH
1. Self-refer: 416-535-8501 x 36019
2. CAMH MD Referral F: 416-595-6821
4.
Addiction Clinical Consult Service
(ACCS):
Tel: 416 595-6968 or toll free 1 888 720-2227.
Hours: 8:00 a.m. to 4:00 p.m., Monday to Friday.
95
Reference:






+


Auriacombe, M., Franques, P., & Tignol, J. (2001). Deaths attributable to methadone vs
buprenorphine in france. JAMA, 285(1), 45
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
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
+
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