Buprenorphine in the OTP, California

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Buprenorphine in the OTP, California

• Judith Martin, MD, FASAM
• Medical Director,
• The 14th Street Clinic
• www.14thstreetclinic.org

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In a nutshell - DATA or 42CFR -methadone or
buprenorphine -specific adjustments
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DATA 2000

• Enables OBOT with sublingual formulations of
  buprenorphine
• Physician must qualify and notify
• Medication prescribed or dispensed
• Audited separately by DEA
• Complaints go to medical board
• 30 patient limit for group.

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Buprenorphine in OTP

• Allowed under Federal Regs since 2003
• Will be used in CA under Federal Regs
• No 30 patient limit
• OTP physician OK without new DEA qualification
• Dispensed only
• Induction and observed dosing altered

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CSAM suggests

• Until medication is covered by Drug-Medi-cal, use
  under DATA 2000. The 42 CFT part 8 regs are
  overly restrictive for this schedule 3
  medication, more flexible use under DATA 2000.
• Only when patient limit becomes a problem,
  consider regular OTP use.

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Medication choiceMethadone vs Suboxone

• Full agonist
• Easier induction
• Less safety
• Oral liquid
• Observed dose easy
• Computerized dispensing easy
• Cheaper
• Tox screen easy

• Partial agonist
• Induction tricky
• Safe for takehome
• Sublingual tablet
• Observed dose takes longer
• Manual pill counting
• Expensive
• Tox screen expensive

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Buprenorphine is a Partial Agonist
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Differences in Precipitated Syndromes

• Buprenorphine will precipitate withdrawal only
  when it displaces a full agonist off the mu
  receptors
• Buprenorphine only partially activates the
  receptors, therefore a net decrease in activation
  occurs and withdrawal develops

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Receptor Affinity

• AFFINITY is the strength with which a drug
  physically binds to a receptor
• Buprenorphines affinity is very strong and it
  will displace full agonists like heroin and
  methadone
• Note receptor binding strength (strong or weak),
  is NOT the same as receptor activation (agonist
  or antagonist)

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Receptor Dissociation

• DISSOCIATION is the speed (slow or fast) of
  disengagement or uncoupling of a drug from the
  receptor
• Buprenorphines dissociation is slow
• Therefore Buprenorphine stays on the receptor a
  long time and blocks heroin or methadone from
  binding

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Methadone Simulated 24 Hr. Dose/ResponseAt
steady-state in tolerant patient
Loaded High
mmt
bup
Normal RangeComfort Zone
Dose Response
Subjective w/d
heroin
Sick
Objective w/d
Time
0 hrs.
24 hrs.
Opioid Agonist Treatment of Addiction - Payte -
1998
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Specific adjustments Patient selection

• System to inform patients and answer questions
  about buprenorphine, fees, etc.
• Easier to move from bup to methadone than v.v.
  (ie, may want to use as first line)
• Pt has to taper to 30 of methadone to transfer.

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Specific adjustmentsDATA 2000 option

• May set up separate billing and charts, if DATA
  2000 is used
• Decision to order RX pads
• Scheduling of doc and counselor time
• Keep 30 patient census
• May use nurses to do pill counts
• May set up special fee structure.

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Specific adjustments under OTP regs.

• Induction timing becomes critical
• What is observed dosing? May take up to 20
  minutes, use waiting room more.
• How to monitor compliance urine test for bup
  expensive, may do pill counts instead
• May want to do MWF dosing
• May ask for exception to daily observed dosing in
  some cases.
• Change DEA license to include schedule 3.

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Useful websites

• CSAT physician locator by zip code
• http//buprenorphine.samhsa.gov/bwns_locator/index
  .html
• CSAM www.csam-asam.org. Has forms and handouts
  on website.
• ASAMs capwiz for info on 30 patient limit bills
  pending. www.asam.org