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Buprenorphine: Introduction (and Induction)

Buprenorphine: Introduction (and Induction). Adam J. Gordon, MD, MPH, FACP, FASAM University of Pittsburgh School of Medicine VA Pittsburgh Healthcare System adam.gordon@va.gov. Drug Abuse Treatment Act (DATA) of 2000.

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Buprenorphine: Introduction (and Induction)

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  1. Buprenorphine: Introduction (and Induction) Adam J. Gordon, MD, MPH, FACP, FASAM University of Pittsburgh School of Medicine VA Pittsburgh Healthcare System adam.gordon@va.gov

  2. Drug Abuse Treatment Act (DATA) of 2000 • Allowed “Qualified” physicians to treat opioid dependence outside methadone facilities • Addiction certification from approved organization, or • 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

  3. Opioid Treatment: Changing Approach Gordon, Counterdetails, 2006

  4. 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

  5. 100 90 Full Agonist (Methadone) 80 70 “Activity” or “Response” 60 Partial Agonist 50 (Buprenorphine) 40 30 20 10 Antagonist (Naloxone) 0 -10 -9 -8 -7 -6 -5 -4 Log DOSE Buprenorphine’s Properties:Partial Agonist Gordon, Counterdetails 2006

  6. Buprenorphine Properties:High Affinity Gordon, Counterdetails, 2006

  7. Buprenorphine Formulations • Formulations and routes • BUPRENEX IVNOT 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)

  8. PO IV SL Diversion potential: Buprenorphine/Subutex Gordon, Counterdetails, 2006

  9. PO IV SL Rationale for Naloxone+Buprenorphine(Suboxone) Gordon, Counterdetails, 2006

  10. 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

  11. 100 73% HI METH 80 60 58% BUP Percent Retained 53% LAAM 40 20 20% LO METH 0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 Study Week Buprenorphine: Treatment Retention Johnson R, NEJM 2000

  12. 100 All Subjects 80 LAAM 49% 60 BUP 40% Mean % Negative HI METH 40 39% LO METH 20 19% 0 1 3 5 7 9 11 13 15 17 Study Week Buprenorphine: “Clean” Urines Johnson R, NEJM 2000

  13. 20 15 Remaining in treatment (nr) 10 Bup 6 day detox 5 Bup Maintenance 0 0 50 100 150 200 250 300 350 Treatment duration (days) Buprenorphine: Retention and Mortality 0 deaths 4 deaths All Patients received group CBT Relapse Prevention, Weekly Individual Counseling, 3x Weekly Urine Screens. n=20 per group Kakko J, Lancet 2003

  14. Buprenorphine: Reduces Other Drug Use Fudala, NEJM 2003

  15. Opioid Dependence Treatment in Primary Care At 24 weeks, 59% remained in treatment Stein, JGIM 2005

  16. Buprenorphine is not diverted OXYCODONE METHADONE BUPRENORPHINE Cicero, NEJM 2005

  17. McLeod, SAMHSA 2005

  18. 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

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