Buprenorphine Therapy in Primary Care:

One Prescriber’s Experience

Pittsburgh, PAAugust 24, 2005

Melinda Campopiano, M.D.

Baron Edmond de Rothschild Chemical Dependency Institute

Opioid Use In Pittsburgh

• Heroin is the most widely abused drug in Pittsburgh

• Surpassed the abuse of Oxycontin in 2002• Nationwide marijuana, crack cocaine and

methamphetamine are most widely abused• In the last 5 years adolescent opiate use has

increased 45%

“Pulse Check” January 2004 Office of National Drug Control Policy

Demographics of Drug Use

• 60 to 62% are male

• 38 to 40% are female, the largest proportion ever

• Majority are suburban

• 65% are white

“Pulse Check” January 2004 Office of National Drug Control Policy

Overdose Death in Pittsburgh

• 2003• 229 deaths• 44% due to heroin• 21 persons under 25

years of age

• Stats courtesy of Dr. Steven A. Koehler, MPH, PhD. Allegheny County Coroner’s Office

• 2004• 205 deaths• 37% due to heroin• 29 persons under 25

years of age

Allegheny County Overdose Deaths

0

50

100

150

200

250

1999 2000 2001 2002 2003 2004

Year

Liv

es

50 and older

25 - 49

Under age 25

Treatment saves lives

French population in 1999 = 60,000,000

1996 Subutex and methadone

1969 1971 1973 1975 1977 1979 1981 1983 1985 1987 1989 1991 1993 1995 1997 1999

Year

No.

of

deat

hs

600

500

400

300

200

100

0

Patients receiving methadone (1998): N= 5,360

Patients receiving buprenorphine (1998): N= 55,000

Auriacombe et al., 2001

Overdose Prevention with Naloxone

• Overdose prevention program with naloxone began summer 2005 and has had one peer reversal of overdose.

Personal Communication, 2005

Treatment DOES Work

• Opioid users in treatment– Use less heroin– Share fewer needles– Need less income from crime – Are in less danger of having a fatal overdose– Have improved social interaction– Reduced HIV seroconversion

• (2000 Drug Misuse Statistic Scotland)

– Improves compliance with medical therapy

Infectious Diseases

• 90% of Injection Drug Users are Hepatitis C Virus positive

• 20% of new HIV infections are in injection drug users and their partners

• Syringe exchange/distribution legalized locally in 2002 makes 6,000+ syringes available weekly

Buprenorphine in medical withdrawal and maintenance

Kaplan-Meier curve of cumulative retention in treatment (Kakko et al, 2003)

Num

ber

rem

aini

ng in

trea

tmen

t

Control

Buprenorphine

Time from randomization (days)

P=0.0001

15

20

10

5

0

0 25020015010050 300 350

What is buprenorphine?

• Receptor Affinity: Partial antagonist – High receptor affinity and receptor occupancy: 95%

occupancy at 16 mg (Greenwald et al, 2003)

– Blockade or attenuate effect of other opioids– Rapid onset of action

• Intrinsic Activity: Partial receptor agonist– Lower physical dependence– Limited development of tolerance– Ceiling effect on respiratory depression

• Slow dissociation– Long duration of action– Milder withdrawal

Suboxone

• Buprenorphine formulated with naloxone as a sublingual tablet

• Buprenorphine is absorbed sublingually

• Naloxone is minimally absorbed and not biologically available

• If the tablet is dissolved and injected the user will experience acute withdrawal

My Experience or: It’s not that complicated.

• Completed Buprenorphine prescriber training 2001

• Drug approved by FDA early 2003

• First prescribed March 2003 using pharmacist-compounded “lozenges”

• Reached 30 patient limit imposed by federal law July 2003

The medical assessment• Drug use history

– Current and past drug use– Quantity, frequency, duration, All drug classes– Assessment of dependence – DSM IV

• Treatment history– Motivations and patient goals– Previous attempts / treatment agents

• Psychiatric history and mental status exam– Psychosocial circumstances – Family history

• Discussion of treatment options– Risks and benefits of treatment– Verbal Consent

• Medical history and physical exam– Clinical lab tests (especially LFT and HCV testing)

My Protocol

• Initial history and physical – 45 minutes to an hour

• Follow-up phone call in 24 hours

• Follow-up visit in one week– Usually 30 minutes

• Monthly evaluation for refill

Precipitated withdrawal or not enough buprenorphine?

0

2

4

6

8

10

12

14

0 2 4 6 8 12 14 16 18 20 22 24 26

Time (hours)

Sev

erity

opi

ate

with

draw

al

Precipitated withdrawal Not enough buprenorphine

Adapted from Lintzeris et al., 2003

Understanding precipitated withdrawal

• Buprenorphine displaces full opioid agonists: – Higher receptor affinity

• Lower level of receptor activation– Patients may experience some

withdrawal symptoms

Promoting a Positive Outcome

• Consider:– Patient expectations of treatment– Patient goals– Stages of change– Current life circumstance– Available resources– Past history of treatment outcomes

Monthly Evaluation for Refill and Brief Therapeutic Interventions

• Motivational interviewing

• Problem Solving Therapy

• Management of other medical problems

• Health maintenance

• Coordination of inpatient rehab care

My Stats

• Total Treated: 74• Average age 36• Youngest 18 • Oldest 59• 54% Male• 46% Female• Only 2 Black• 80% using heroin

The Other 31

• 10 in recovery• 10 lost to follow up• 1 on methadone• 1 moved away• 1 incarcerated• 3 chronic pain• 4 fired

Keys to Success in Practice

• Provide a contract for treatment outlining expected behaviors and unacceptable behaviors.

• Employ a written consent for withdrawal from buprenorphine therapy.

• At least monthly visits once stabilized• Ask regularly about 12 steps/sponsor/home meeting etc.• Learn the basics of Motivational Interviewing and

Problem Solving Therapy.• Screen and treat (or refer) for depression and attention

deficit disorder.• Develop familiarity with outpatient management of

benzo, ETOH and cocaine withdrawal.• Facilitate inpatient treatment.

Harm Reduction in Practice

• If at first you don’t succeed, redefine success.

• Meet them where they’re at– Work on what’s bothering them rather than

what’s bothering me

• Have low threshold access– Same day and walk-in appointments

Dana Davis, Allegheny General Hospital Positive Health Center, Pittsburgh, PA