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: