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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
1992- 2003 use of opioids increased at a
rate of 140.5% (CNS depressants 44.5%,
Stimulant (41.5% and heroin (1.5%)
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.
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
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
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.
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”
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
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
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
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
Does it work – Who knows
400,000 patients world wide have been
treated
In short term clinical trials 18% had opioidnegative urines versus 6% on placebo
Craving scores reduced (52% versus
16%)
6-month retention 42% to 72%
Dependence/Abuse
 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.
Recovery from Opioid Dependence is a
Counseling Program
Psychotherapy
Family Counseling
Parenting
Behavioral
LOSS OF CONTACT WITH THE
RECOVERING COMMUNITY USUALLY
LEADS TO RELAPSE
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
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
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