2. Ken Saffier, MD, Natasha Pinto, MD And Patients CCRMC/HC Noon Conference February 18, 2010

3. Drs. Pinto and Saffier have no financial interest or other relationship with the manufacturer of any commercial product discussed in this presentation.

4. 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.

5. 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

6. Over 2 million are estimated to be dependent on or abusing prescription drugs in the past year. Past Year Dependent/Abusers, Ages 12 or Older (in Thousands) Source: SAMHSA, 2002 National Survey on Drug Use and Health. 1/2004

7. No year-to-year differences are statistically significant. Percent of 12th Graders Reporting Nonmedical Use of OxyContin and Vicodin in the Past Year Remained High Percent of 12th Graders Reporting Nonmedical Use of OxyContin and Vicodin in the Past Year Remained High 9.6 10.5 9.3 0.0 2.0 4.0 6.0 8.0 10.0 12.0 OxyContin Vicodin 2002 2003 2004 4.0 4.5 5.0 Percent Issues of Concern

8.  Agonist  Heroin, hydrocodone, oxycodone, fentanyl  Antagonist  Naloxone, naltrexone  Mixed agonist/antagonist  Pentozacine, butorphanol (Stadol)  Partial agonist  Buprenorphine

9. -10-9-8-7-6-5-4 0 10 20 30 40 50 60 70 80 90 100 Intrinsic Activity Log Dose of Opioid Full Agonist (Methadone) Partial Agonist (Buprenorphine) Antagonist (Naloxone) Intrinsic mu Activity: Full Agonist (Methadone), Partial Agonist (Buprenorphine), Antagonist (Naloxone)

10.  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

12. Zubieta et al., 2000

13.  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)

14.  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

15.  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.

17.  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.

19.  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

21.  Buprenorphine maintenance  Short acting opioids  Long acting opioids  Buprenorphine detox  Buprenorphine taper  (As an analgesic (buprenex))

22. Treatment duration (days) Remaining in treatment (nr) 0 5 10 15 20 050100150200250300350 Detoxification Maintenance 4 Subjects in Control Group Died

24.  Our patients, especially Ryan.  Drs. Michael Saxon and Mary Jeanne Kreek  Chris Verdugo, CCTV  Gary Larson

26. www.buppractice.com (discounted for residents)

27.  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.h tml#top  www.csam-asam.org