Buprenorphine group treatment for opioid addiction
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Buprenorphine Group Treatment For Opioid Addiction. Ken Saffier , MD, Natasha Pinto, MD And Patients CCRMC/HC Noon Conference February 18, 2010. Disclosures.

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Buprenorphine Group Treatment For Opioid Addiction

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Buprenorphine group treatment for opioid addiction

Buprenorphine Group Treatment For Opioid Addiction

Ken Saffier, MD, Natasha Pinto, MD

And Patients

CCRMC/HC Noon Conference

February 18, 2010


Disclosures

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

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.


Buprenorphine group treatment for opioid addiction

Number of mentions

. Oxycodone and hydrocodone both registered substantial increases in emergency department mentions in the last 5 years

Source: SAMHSA, Drug Abuse Warning Network.

2/2004


Buprenorphine group treatment for opioid addiction

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

  • Over 2 million are estimated to be dependent on or abusingprescription drugsin the past year.

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

1/2004


Buprenorphine group treatment for opioid addiction

Issues of Concern

Percent of 12th Graders Reporting

Nonmedical Use of OxyContin and Vicodin

in the Past Year Remained High

12.0

10.5

9.6

9.3

10.0

8.0

Percent

6.0

5.0

4.5

4.0

4.0

2.0

0.0

OxyContin

Vicodin

2002

2003

2004

No year-to-year differences are statistically significant.


Opioids a brief overview

Opioids – a brief overview

  • Agonist

    • Heroin, hydrocodone, oxycodone, fentanyl

  • Antagonist

    • Naloxone, naltrexone

  • Mixed agonist/antagonist

    • Pentozacine, butorphanol (Stadol)

  • Partial agonist

    • Buprenorphine


Buprenorphine group treatment for opioid addiction

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

100

90

Full Agonist

(Methadone)

80

70

Intrinsic Activity

60

Partial Agonist

50

(Buprenorphine)

40

30

20

10

Antagonist (Naloxone)

0

-10

-9

-8

-7

-6

-5

-4

Log Dose of Opioid


Buprenorphine a partial agonist

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


Buprenorphine group treatment for opioid addiction

Zubieta et al., 2000


Buprenorphine a partial agonist1

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

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

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 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

Opioid Withdrawal


Uses of buprenorphine

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

Buprenorphine vs. Placebo for Heroin DependenceKakko, Lancet 2003

20

15

Remaining in treatment (nr)

4 Subjects in Control Group Died

10

Detoxification

5

Maintenance

0

0

50

100

150

200

250

300

350

Treatment duration (days)


Special thanks

Special Thanks:

  • Our patients, especially Ryan.

  • Drs. Michael Saxon and Mary Jeanne Kreek

  • Chris Verdugo, CCTV

  • Gary Larson


Buprenorphine clinical guidelines

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

Buprenorphine Course

www.buppractice.com

(discounted for residents)


For further information

For further information:

  • Buprenorphine at CCRMC & HC’s:

    • 925 370 5868 (leave message)

      or

    • 925 370 5859 (leave message)

    • Call Ken Saffier, MD, pager 334

  • http://buprenorphine.samhsa.gov/about.html#top

  • www.csam-asam.org


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