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New Uses for an Old Med

New Uses for an Old Med. Buprenorphine and Out-Patient Detoxification. Is it a problem in your practice. 1.6 Million People dependent on or abuse opioid analgesics and heroin (National Survey of Drug Use and Health 2003) 4.4 Million People use prescription pain medication non-medically

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New Uses for an Old Med

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  1. New Uses for an Old Med Buprenorphine and Out-Patient Detoxification

  2. Is it a problem in your practice • 1.6 Million People dependent on or abuse opioid analgesics and heroin (National Survey of Drug Use and Health 2003) • 4.4 Million People use prescription pain medication non-medically • 1992- 2003 use of opioids increased at a rate of 140.5% (CNS depressants 44.5%, Stimulant (41.5% and heroin (1.5%)

  3. Is it a problem in your practice • In ED, 450% increase in the recording of Oxycodone use (170% increase Hydrocodone) 1994-2002 • Women accounted for 55% of Nonmedical use of Opioid Analgesics in 2002.

  4. Who is at increased risk • Family history of opioid dependence or other substance abuse • Habituated patients from painful injury or condition • Psychiatric disorders including depression, anxiety, bi-polar • Infectious comorbidities (Hep C, HIV) • Professional with easy access • Recreational Use

  5. A “Brain Disease” per WHO • Pervasive and persistent changes in cognitive and drug-rewarding circuits • Significant alterations at the neurochemical, molecular and cellular levels • Changes to brain structure and function that persist long after drug use has stopped

  6. Opioid Dependence and the Brain • Opioid attachment to mu-opioid receptors induce changes in the locus ceruleus • Changes in the locus ceruleus suppress release of noradrenalin which result in symptoms of opioid intoxication (drowsiness, slowed respiration, low blood pressure) • Repeat exposure causes adaptation of LC of increasing noradrenalin production • Lack of opioids to suppress LC neurons, cause excessive release of NA producing withdrawal.

  7. The Withdrawal Syndrome • Signs and symptoms of opioid withdrawal syndrome include yawning, sweating, lacrimation, rhinorrhea, anxiety, restlessness, insomnia, dilated pupils, piloerection, chills, tachycardia, hypertension, nausea/vomiting, crampy abdominal pains, diarrhea, and muscle aches and pains. Unlike withdrawal from alcohol or benzodiazepines, opioid withdrawal is not life threatening. Emergence of withdrawal symptoms varies with half-life of the particular opioid • Often followed by “the craves”

  8. Approaches to Withdrawal • “Cold Turkey” • Replacement Therapy • Methadone – only in federally approved clinics • Often very long term • Buprenorphine – out-patient, physician’s office or clinic

  9. The Theory of Why Buprenorphine • Partial opioid agonist with high mu-opioid receptor affinity and lower intrinsic activity • Lower physical dependence and euphoric effect • Suppress opioid withdrawal symptoms, decrease cravings (improve treatment retention and reduce illicit opiod use • Partially block effect of subsequent opioids by keeping them away from mu-receptors

  10. Safety Profile • Risk of fatal respiratory depression much less than full agonist because of “ceiling effect” -- i. e. effect on the body levels off after a certain amount. • With other pure agonist – above respiratory depression level • With buprenorphine -- below

  11. Available Forms of Drug • Subutex – pure buprenorphine • Suboxone – buprenorphine plus naloxone • Naloxone (Narcan) reduces likelihood of crushing and shooting or snorting by attenuating the effects of buprenorphine • Suppose to reduce diversion and abuse • Stop signs $1/mg on the street

  12. Does it work – Who knows • 400,000 patients world wide have been treated • In short term clinical trials 18% had opioid-negative urines versus 6% on placebo • Craving scores reduced (52% versus 16%) • 6-month retention 42% to 72%

  13. Dependence Tolerance for opioid Withdrawal symptoms Larger amounts and longer period than normal recovery Persistent desire or repeated attempts to quit Much time devoted to obtain, use, recover Interferes with social, occupational, or recreational activity Use persists despite knowledge of adverse consequences Abuse Recurrent use in spite of physically hazardous situations Marital and family problems – abuse/violence Recurrent substance-related legal problems Continued use despite persistent or recurrent social or interpersonal problems caused or exacerbated by opioid. Dependence/Abuse

  14. Recovery from Opioid Dependence is a Counseling Program • Psychotherapy • Family Counseling • Parenting • Behavioral LOSS OF CONTACT WITH THE RECOVERING COMMUNITY USUALLY LEADS TO RELAPSE

  15. Prescribing Suboxone in the Office Setting • Must become certified by taking a recognized training program – available on-line • Receive new (additional) DEA Registration Number • Restricted to 30 patients in first year • May expand to 100 after 1 year of practice

  16. My clinical Experience • Registered in February, 2007 • Work only with patients/clients of The Counseling Center • Goal is to wean within 5 to 6 months • Treated 48 patients since February • Currently 25 active, 23 in-active • Of 23 In-active 6 completely tapered

  17. Does it work • Who knows • Few long term studies of success • Difficult to design/difficult to collect data/expensive to run • Little literature on optimum way to manage program

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