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. Physician in clinical trial of qualifying medication, or
3. 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
Office-Based treatments
• Criteria:
Withdrawal
12 months use
• Dose regulated
• Criteria:
DSM IV
No time criteria
• MD sets dose
• Age > 18
• Age > 16
• Limited take homes
• Take homes (30 days)
• Services “required”
• 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
Partial Agonist
(Buprenorphine)
50
40
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
Incorrect
Incorrect
Correct
Route
Oral
IV (diversion)
Sublingual
Buprenorphine Absorbed?
NO
YES
YES
Naloxone Absorbed?
NO
YES!!!
NO !
Outcome

Pt: 
MD: 
!
(No Action)
Gordon, Counterdetails, 2006
Rationale for Naloxone+Buprenorphine
(Suboxone)
PO
IV
SL
Incorrect
Incorrect
Correct
Route
Oral
IV (diversion)
Sublingual
Buprenorphine Absorbed?
NO
YES
YES
Naloxone Absorbed?
NO
YES!!!
NO !
Outcome


!
(No Action)
(withdrawal)
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
Percent Retained
100
73% HI METH
80
60
58% BUP
40
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
Mean % Negative
100
All Subjects
80
LAAM
49%
60
BUP
HI METH
40%
40
39%
20
LO METH
19%
0
1
3
5
7
9
11
13
15
17
Study Week
Johnson R, NEJM 2000
Remaining in treatment (nr)
Buprenorphine: Retention and Mortality
0 deaths
20
15
10
4 deaths
Bup 6 day detox
Bup Maintenance
5
0
0
50
100
150
200
250
Treatment duration (days)
300
350
All Patients received group CBT
Relapse Prevention, Weekly
Individual Counseling, 3x Weekly
Urine Screens. n=20 per group
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