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
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
Gordon, Counterdetails, 2006
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Rationale for NaloxoneBuprenorphine(Suboxone)
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