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PHARMACOLOGIC TREATMENT OF
OPIATE DEPENDENCE
Paula Colescott MD
Diplomat of The American Board of Addiction Medicine
Board Certification in Internal Medicine
Objectives
The student will understand:
• The Brain changes in the addict
• The Historical Approaches of Treatment
• Agonist Treatment
• Blockade of the Opiate Receptor
• Those who qualify for Buprenorphine/Naltrexone
• The Clitheroe Protocol
In Reflection
• 25 yo Native Female, IV heroin user ,being released from Hiland Prison. She is tremulous as she tells me she doesn’t think she can stay clean.
• 30 yo white female, narcotic/heroin user, who is in RSAT @ Hiland Prison. She confides to me that despite treatment she fears her inability to resist relapse.
OPIATESDerived from extracts of the juice of opium poppy.
OPIOIDSAny exogenous substance that acts as an agonist at any of
several receptors
Neurobiology of Addiction
George F. Koob
Take a Drug Change Your Brain
DRUG ADDICTION IS A COMPLEX ILLNESSDRUG ADDICTION IS A COMPLEX ILLNESS
www.drugabuse.gov
Steward, 1987, p. 166
“It’s staying off that is the hard part. It
takes a lot of willpower. But seeing
smack eats away at your willpower; it
makes it very hard. When I stop I just
feel vacant with no direction or
energy and that lasts for months.’
Behavioral Mechanisms of Addiction
“The special role the drug comes to play in the personality organization of these patients. They have not successfully established familiar defensive, neurotic, characterological or other common adaptive mechanisms as a way of dealing with their distress. Instead, they have resorted to the use of opioids as a way of coping with a range of problems including ordinary human pain, disappointment, anxiety, loss, anguish, sexual frustration, and other suffering”
Opioids relieve emotional painand this is one of the behavioral mechanisms implicated in the
addiction cycle (Khantzian, 1985, 1990, 1997)
Opioid Intoxication
1st Profound euphoria the rush Visceral sensations, a facial flush, deepening of the voice. The
rush is resistant to tolerance.
2nd The High feeling of well-being over several hours, no tolerance
3rd The Nod state of escape from reality ranging
from sleepiness to virtual unconsciousness
4th Being Straight User no longer experiencing the rush or nod or high, but also not in withdrawal. This can
last up to 8 h following an injection or smoking of heroin.
Substance Dependence (brief)
• Organization around acquisition, use, recovery from effects, of the drug—behavior is rewarding
• Dosage and frequency not the issue
• Consequences are the issue
• Adaptation and deterioration are hallmarks
• Ambivalence is the psychodynamic
– Loss of CONROL
Acute Withdrawal5-7 Days
• Runny nose, sneezing,
• Sweating, yawning
• Restless, insomnia
• Piloerection, myalgia
• Twitching, arthralgia
• Abd. Cramps, diarrhea
• Vomiting, dehydration
• Tachycardia, HBP, Fever
• Psychosis
• Autonomic rebound locus ceruleus
•
Protracted (1-12 months) Abstinence
• Anergia, Anhedonia
• Sleep disturbance
• Poor appetite
• Emotional lability/dysphoria
• Stress incompetence
• Drug craving, obsession
• Muscle aches and pains
• Reduced libido, impotence
• Dopaminergic deficiency,
nucleus accumbens, VTA
WHY TREAT OPIOID DEPENDENCE WITH OPIOID AGONISTS?
Repeated Exposure
Neuronal Adaptation
Tolerance, physical dependence, craving
Chronic relapsing nature of opioid dependence
Medical Withdrawal from Opioids
1. Cold Turkey
2. Symptomatic Medications/Social SupportClonidine, ibuprofen, hydoxyzine, methocambanol, loperamide…
3. Taper ( Goodman & Gilman: 20-50% decrease/day)
4. Federally regulated methadone clinic
5. Ultra-Rapid Opioid Detox (UROD), Rapid Opioid Detox
6. Buprenorphine –(suboxone/subutex)
7. Blockade of the Opiate Receptor ?
Medical Withdrawal or “Detox” is not treatment
Treatment Overview of Opioid Dependence
DEATH
HARM REDUCTION
OPIOID
REPLACEMENT
Methadone or buprenorphine
ABSTINENCE
< 20% CAN ACHIEVE THIS
Naltrexone
Needle Exchange Program
Is Clean & Sober too Much to ask with Opiates??
OpioidReplacement
Methadone=76% Buprenorphine=?
Abstinence Detox only
3% @ 1 yr
MJ Kreek<20% in
lifetime
WA state MDs85% @ 10 yrs.
New History
1960-70s Dole, Nyswander, and Kreek• Proposed addiction to be a change in brain from
prolonged exposure to opiates
• Started evaluating methadone in the early 1960s
• Methadone for dependence/addiction Rx in special clinics
Buprenorphine
(Subutex)
Orphan drug developed by NIDA and private
pharmaceutical interest over 25 years
2000 Drug Addiction Treatment Act• Addiction is a chronic disease
• Physicians may offer buprenorphine treatment, as a
replacement therapy in their office “OBOT” –Office Based
Opioid Therapy (need 8h CME)
• PCP knows the patient, the family, “the story”
• Reduces stigma, increases access to care
• Aligns addiction with other chronic relapsing conditions
(asthma, HBP, DM, Obesity, depression, mental illness, etc.)
Cognitive Behavioral TherapiesSubstance abuse is related to maladaptive
social learning/adverse life situations.
• Improve interpersonal &Coping skills
– Evaluating feelings, thoughts
• Self-efficacy
– Teach problem solving
Reduce risk of relapse
– Triggers, cues
– Coping with urges
“As a Man thinks, so is he”
Solomon
Is Buprenorphine an Analgesic?
• Yes• 20-40 X as potent as morphine
• Analgesic in US, Buprenex (IV/IM), for decades
• Worldwide use for pain as Temgesic
• There is no FDA approval for pain(SL), but it is prescribed to pain patients “off-label”
[problematic]
Opioid Receptors and Effect of Agonist
Mu1 (μ1) analgesia, euphoria
Mu2 (μ2) constipation, respiratory depression
Kappa spinal analgesia, dysphoria
Delta unknown
Receptor Binding at Mu receptor
Agonist
Partial Agonist
Antagonists
Morphine-like effect, increasing dose increases effect
Morphine-like effect with strong receptor affinity, slow dissociation, ceiling effect (bup)
No effect in absence of an opiate or opiate dependence (e.g., naltrexone)
Function at Receptors: Full Agonists
Mureceptor
Full agonist binding …
activates the mu receptor at higher levels with higher doses
is highly reinforcing
is the most abused opioid type
includes, oxycodone, morphine,methadone, others
Slide Courtesy of John T. Pichot, MD
Opioid Receptor Partial Agonists
Mureceptor
activates the receptor at lower levels but plateaus at lower levels
is relatively less reinforcing
is a less abused opioid type
includes buprenorphine
Partial agonist binding …
Slide Courtesy of John T. Pichot, MD
Full Agonist Bound to Receptor
Bup affinity is higher
Therefore Full Agonist is displaced
Partial Agonist (Bup) Receptor Affinity
MuReceptor
• Strength: Drug physically binds to a receptor
Buprenorphine affinity is very strong and it will displace full agonists like morphine and methadone
Can precipitate withdrawal
Slide Courtesy of John T. Pichot, MD
Receptor Dissociation
• Speed (slow or fast) of disengagement or uncoupling of a drug from the receptor
• Buprenorphine’s dissociation is slow – Blocks other opioids (ie morphine) from binding
– Prolonged therapeutic effect (> 24 hours)
MuReceptor
Bup dissociation is slow
Therefore Full Agonists can’t bind
Slide Courtesy of John T. Pichot, MD
0
10
20
30
40
50
60
70
80
90
100
2 mg 16 mg 32 mg
Dose
% R
ecep
tor
Occ
up
an
cy
Source: Greenwald, MK et al, Neuropsychopharmacology 28, 2000-2009, 2003.
μEffects of Buprenorphine Maintenance Dose on
Mu Opioid Receptor Availability
27 to 47%
85 to 92%94 to 98%
Benefits of Buprenorphine• Mild withdrawal syndrome
• Prolonged therapeutic effect
• Safe and effective as an analgesic
• Blockade of “illicit” opioids
• Greater safety margin compared to methadone
• Decreased risk of abuse and diversion with combination tablet
• Efficacy comparable to methadone
Usual Effect of Buprenorphine Induction in an Opiate Dependent Patient
“Normal”
Withdrawal
High
Opiate
Effects
“Normal”
Withdrawal
Effects of Using Heroin while on Buprenorphine
High
Attenuated
rushOpiate
effects
CESAR FAXU n i v e r s i t y o f M a r y l a n d , C o l l e g e P a r k
A Weekly FAX from the Center for Substance Abuse Research
April 9, 2012
Vol. 21, Issue 14
Northeastern and Southern Regions of Country Account for Largest Increases in Buprenorphine Found in Law Enforcement Drug Seizures
2003 2004 2005 2006 2007 2008 2009 2010
0
500
1,000
1,500
2,000
2,500
3,000
3,500
4,000
4,500
831
1,689
4,161
3,856
West
Midwest
Northeast
South
Estimated Number of Buprenorphine Reports,
U.S. Law Enforcement-Seized Drug Exhibits Analyzed by Forensic Laboratories,
by U.S. Census Region*, 2003-2010
*Northeast: CT, MA, ME, NH, NJ, NY, PA, RI, VT
South: AL, AR, DC, DE, FL, GA, KY, LA, MD, MS, NC, OK, SC, TN, TX, VA WV
Midwest: IA, IL, IN, KS, MI, MN, MO, ND, NE, OH, SD, WI
West: AK, AZ, CA, CO, HI, ID, MT, NM, NV, OR, UT, WA, WY
Buprenorphine estimates for the South and West regions do not meet the DEA’s standard of precision and reliability.
Patient Selection: 10 Assessment Questions
• Is the patient dependent/addicted to opioids?
• Does the Client live in Anchorage?
• Is the patient aware of other available treatment options?
• Does the patient understand the risks, benefits, and limitations of buprenorphine treatment?
• Is the patient expected to be reasonably compliant, with all treatment modalities?
• Is the patient able to follow safety procedures?
Patient Selection: 10 Assessment Questions
• Is the patient psychiatrically stable?
• Is the patient taking other medications that may interact with buprenorphine?
• Are the psychosocial circumstances of the patient stable and supportive?
• Is the patient interested in office-based buprenorphine treatment?
• Are there resources available in the office to provide appropriate treatment, and support?
• Do they have a means of paying for the Suboxone?
Less Likely to be an Appropriate Candidate:
• High BNZ doses, alcohol, other CNS depressants• Significant psychiatric co-morbidity• Multiple addiction treatment episodes (+ -??)• Actively or chronic suicidal or homicidal ideation• Needs that cannot be addressed with existing office-
based resources or through referrals
• High daily doses of methadone ( 40mg+/day)
• Poor social support system—Cannot be living with IV opiate user . Cannot be employed by Business linked to drug use
How do you determine Dependence?
DSM-IV requirements:3 or more needed x 12 months– Tolerance– Withdrawal– Larger amt. longer period than intended – Any unsuccessful effort / persistent desire to cut down
/control substance use – A lot of time spent obtaining / recovering– Important social, occupational, or recreational
activities given up / reduced– Continuation despite consequences caused or
exacerbated by the substance
Narcotic / Alcohol Dependent
• Do CIWA and COWS scale
• Treat according to the CIWA/ETOH protocol
• This patient is NOT a candidate for suboxone
• This patient is a good candidate for NALTREXONE maintenance once they finish withdrawing from ETOH.
• They can be made comfortable with BZDs, clonidine, phenergan or zofran
The Narcotic/Alcohol Dependent
• Suboxone possible If – they contract to remain in residential treatment for
90 days– Their counselors confirm their investment in recovery– They have no underlying psych co-morbidity– Upon release they have a stable living situation – Upon release they remain in IOP– Upon release they have the finances to obtain
suboxone consistently.– They agree to be on a monitored ANTABUSE
PROGRAM