Buprenorphine: Pre-Incarceration Experience of Inmates in Two Prison SAP Programs; Pre-Recovery Experience of Partici

1. Buprenorphine: Pre-Incarceration Experience ofInmates in Two Prison SAP Programs; Pre-Recovery Experience of Participants in a Large Indigent Recovery Program Burns M. Brady, MD, ASAM, FASAM, ABFP, FAAFP

2. 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 I. Opioid Replacement and  Maintenance Therapy

3. 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)

4. 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)

5. �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.� Principles of Addiction Medicine Opioid Maintenance Therapy

6. 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 II. Legal and FDA Parameters

7. 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 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 III. Buprenorphine as Maintenance  Drug of Choice

8. 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)

9. 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.

10. 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.�

11. 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�

12. 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

13. 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.

14. 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.

15. 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. IV. Conclusion

16. 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.

17. 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

18. 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).

19. 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.

20. As I was taught so appropriately and profoundly: �To discern the correct diagnosis and conclude the best treatment � listen to the patient.�