1. Buprenorphine Therapy in Primary Care: One Prescriber’s Experience Pittsburgh, PA August 24, 2005 Melinda Campopiano, M.D. Baron Edmond de Rothschild Chemical Dependency Institute

2. 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

3. 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

4. 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

6. Treatment saves lives French population in 1999 = 60,000,000 1996 Subutex and methadone 196919711973197519771979198119831985198719891991199319951997 1999 Year No. of deaths 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

7. Overdose Prevention with Naloxone Overdose prevention program with naloxone began summer 2005 and has had one peer reversal of overdose. Personal Communication, 2005

8. 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

9. 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

10. Buprenorphine in medical withdrawal and maintenance Kaplan-Meier curve of cumulative retention in treatment (Kakko et al, 2003) Number remaining in treatment Control Buprenorphine Time from randomization (days) P=0.0001 15 20 10 5 0 025020015010050300350

11. 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

12. 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

13. 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

14. 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)

15. 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

16. Precipitated withdrawal or not enough buprenorphine? Adapted from Lintzeris et al., 2003

17. Understanding precipitated withdrawal Buprenorphine displaces full opioid agonists: –Higher receptor affinity Lower level of receptor activation –Patients may experience some withdrawal symptoms

18. Promoting a Positive Outcome Consider: –Patient expectations of treatment –Patient goals –Stages of change –Current life circumstance –Available resources –Past history of treatment outcomes

19. 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

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

21. The Other 31 10 in recovery 10 lost to follow up 1 on methadone 1 moved away 1 incarcerated 3 chronic pain 4 fired

22. 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.

23. 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