BUPRENORPHINE GROUP TREATMENT FOR OPIOID

ADDICTION

Ken Saffier, MD, Natasha Pinto, MDAnd Patients

CCRMC/HC Noon ConferenceFebruary 18, 2010

Disclosures

Drs. Pinto and Saffier have no financial interest or other relationship with the manufacturer of any commercial product discussed in this presentation.

Learning Objectives

At the end of this presentation, participants will be able to:

List at least 2 patient criteria needed for buprenorphine treatment.

Explain why an opioid dependent patient must be in opioid withdrawal prior to taking their first dose of buprenorphine.

Understand and experience aspects of what a buprenorphine treatment group is like.

Number of mentions

0

10,000

20,000

30,000

1995 1996 1997 1998 1999 2000 2001 2002

Hydrocodone Oxycodone

. Oxycodone and hydrocodone both registered substantial increases in emergency department mentions in

the last 5 years

Source: SAMHSA, Drug Abuse Warning Network.2/2004

Over 2 million are estimated to be dependent on or abusing prescription drugs in the past year.

180

214

426

1,488

2,018

4,294

0 1,000 2,000 3,000 4,000 5,000

Inhalants

Heroin

Hallucinogens

Cocaine

Prescription Drugs

Marijuana

Past Year Dependent/Abusers, Ages 12 or Older (in Thousands)

Source: SAMHSA, 2002 National Survey on Drug Use and Health.1/2004

No year-to-year differences are statistically significant.No year-to-year differences are statistically significant.

Percent of 12th Graders Reporting Nonmedical Use of OxyContin and Vicodin

in the Past Year Remained High

Percent of 12th Graders Reporting Nonmedical Use of OxyContin and Vicodin

in the Past Year Remained High

9.69.610.510.5

9.39.3

0.00.0

2.02.0

4.04.0

6.06.0

8.08.0

10.010.0

12.0

OxyContin OxyContin Vicodin Vicodin

20022002 20032003 20042004

4.04.0 4.54.5 5.05.0

Per

cen

tP

erce

nt

Issues of ConcernIssues of Concern

Opioids – a brief overview

Agonist Heroin, hydrocodone, oxycodone, fentanyl

Antagonist Naloxone, naltrexone

Mixed agonist/antagonist Pentozacine, butorphanol (Stadol)

Partial agonist Buprenorphine

-10 -9 -8 -7 -6 -5 -40

10

20

30

40

50

60

70

80

90

100

Intrinsic Activity

Log Dose of Opioid

Full Agonist(Methadone)

Partial Agonist(Buprenorphine)

Antagonist (Naloxone)

Intrinsic mu Activity: Full Agonist (Methadone), Partial Agonist (Buprenorphine), Antagonist (Naloxone)

Buprenorphine – a partial agonist

High affinity for the mu opioid receptor Competes with other opioids and blocks their effects Can precipitate withdrawal in highly opioid

dependent individuals Slow dissociation from the mu receptor

Prolonged therapeutic effect for opioid dependence treatment

“Ceiling effect” for stimulation of a given receptor

Human Opioid Receptors , , and

LaForge, Yuferov and Kreek, 2000

extracellular fluid

cell interior

cell membrane

AA identical in 3 receptors

AA identical in 2 receptors

AA different in 3 receptors

HOOC

H2N

S

S

Zubieta et al., 2000

Buprenorphine – a partial agonist

Poor oral bioavailability Fair sublingual bioavailability Takes about 10 minutes to dissolve Schedule III drug With naloxone (4:1) (Suboxone) or without

(Subutex) Analgesic dose for mild to moderate pain is 0.3

– 0.6 mg. (0.4 mg = ~10 mg morphine)

Who is an appropriate patient?

Opioid dependent Wants to stop using Psychiatrically stable Interested in office-based care Reliable – can keep appointments Agrees to urine tox screens Has social support

Meet Ryan -

Went to the ED in withdrawal. Longstanding use of OxyContin. $100/day “habit”. Snorts q day for months, then stops. Moves back to the Bay Area and within

days, he’s back to using.

“I’m tired of snorting Oxies, Doc. Can you help me?”

I’m snorting 5 oxies per day – it’s an insane amount to be putting into my body.

My palms are sweaty in the morning. Then I have intense pain in my thighs. I feel fidgety to an extreme. So much physical and mental anguish. I don’t want to waste money on this. It’s

destroying my life.

Opioid Withdrawal

Dysphoric mood Craving Irritability Tearing,

rhinorrhea Fever, chills Sweating Gooseflesh (cold

turkey) Dilated pupils

Muscle aches Back pain Tremor Yawning Restless sleep,

then Insomnia Anorexia N/V, diarrhea,

cramps

Uses of Buprenorphine

Buprenorphine maintenance Short acting opioids Long acting opioids

Buprenorphine detox Buprenorphine taper (As an analgesic (buprenex))

Buprenorphine vs. Placebo for Heroin Dependence

Kakko, Lancet 2003

Treatment duration (days)

Rem

ain

ing in t

reatm

ent

(nr)

0

5

10

15

20

0 50 100 150 200 250 300 350

Detoxification

Maintenance

4 Subjects in Control Group Died

Special Thanks:

Our patients, especially Ryan.

Drs. Michael Saxon and Mary Jeanne Kreek

Chris Verdugo, CCTV

Gary Larson

Buprenorphine Clinical Guidelines

Substance Abuse and Mental Health Administration Center for Substance Abuse Treatment

Treatment Improvement Protocol (TIP) Series

Clinical Guidelines for the Use of Buprenorphine in the Treatment of Opioid Addiction # 40

National Clearinghouse for Alcohol and Drug Information (800) 729 – 6686 or (301) 468 – 2600

http://ncadi.samhsa.gov

Buprenorphine Course

www.buppractice.com

(discounted for residents)

For further information: