Buprenorphine: Introduction (and Induction)

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Buprenorphine Introduction (and Induction)

• Adam J. Gordon, MD, MPH, FACP, FASAM
• University of Pittsburgh School of Medicine
• VA Pittsburgh Healthcare System
• adam.gordon_at_va.gov

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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

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Opioid Treatment Changing Approach
Methadone Clinic Office-Based treatments
Criteria Withdrawal 12 months use Criteria DSM IV No time criteria
Dose regulated MD sets dose
Age gt 18 Age gt 16
Limited take homes Take homes (30 days)
Services required Services must be available
Gordon, Counterdetails, 2006
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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

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Buprenorphines PropertiesPartial Agonist
Gordon, Counterdetails 2006
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Buprenorphine PropertiesHigh Affinity
Gordon, Counterdetails, 2006
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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)

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Diversion potential Buprenorphine/Subutex
Incorrect Incorrect Correct
Route Oral IV (diversion) Sublingual
Buprenorphine Absorbed? NO YES YES
Naloxone Absorbed? NO YES!!! NO !
Outcome ? (No Action) Pt ? MD ? !
Gordon, Counterdetails, 2006
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Rationale for NaloxoneBuprenorphine(Suboxone)
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
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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

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Buprenorphine Treatment Retention
Johnson R, NEJM 2000
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Buprenorphine Clean Urines
Johnson R, NEJM 2000
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Buprenorphine Retention and Mortality
0 deaths
4 deaths
All Patients received group CBT Relapse
Prevention, Weekly Individual Counseling, 3x
Weekly Urine Screens. n20 per group
Kakko J, Lancet 2003
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Buprenorphine Reduces Other Drug Use
Fudala, NEJM 2003
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Opioid Dependence Treatment in Primary Care
At 24 weeks, 59 remained in treatment
Stein, JGIM 2005
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Buprenorphine is not diverted
OXYCODONE
METHADONE
BUPRENORPHINE
Cicero, NEJM 2005
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McLeod, SAMHSA 2005
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Useful Websites

• Buprenorphine Information www.buprenorphine.samhs
  a.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