Buprenorphine in the OTP, California Judith Martin, MD, FASAM Medical Director, The 14th Street Clinic www.14thstreetclinic.org 2004, COMP meeting In a nutshell: - DATA or 42CFR -methadone or buprenorphine -specific adjustments 2004, COMP meeting DATA 2000 Enables OBOT with sublingual formulations of buprenorphine Physician must qualify and notify Medication prescribed or dispensed Audited separately by DEA Complaints go to medical board 30 patient limit for ‘group’. 2004, COMP meeting Buprenorphine in OTP Allowed under Federal Regs since 2003 Will be used in CA under Federal Regs No 30 patient limit OTP physician OK without new DEA qualification Dispensed only Induction and observed dosing altered 2004, COMP meeting CSAM suggests: Until medication is covered by DrugMedi-cal, use under DATA 2000. The 42 CFT part 8 regs are overly restrictive for this schedule 3 medication, more flexible use under DATA 2000. Only when patient limit becomes a problem, consider regular OTP use. 2004, COMP meeting Medication choice: Methadone vs Suboxone Full agonist: Partial agonist Easier induction Less safety Oral liquid Observed dose easy Computerized dispensing easy Cheaper Tox screen easy Induction tricky Safe for takehome Sublingual tablet Observed dose takes longer Manual pill counting Expensive Tox screen expensive 2004, COMP meeting 2004, COMP meeting Buprenorphine is a Partial Agonist 100 90 Full Agonist (e.g. heroin) 80 70 60 Partial Agonist (e.g. buprenorphine) % 50 Mu Receptor 40 Intrinsic Activity 30 20 10 0 Antagonist (e.g. naloxone) no drug low dose DRUG DOSE 2004, COMP meeting high dose Differences in Precipitated Syndromes Buprenorphine will precipitate withdrawal only when it displaces a full agonist off the mu receptors Buprenorphine only partially activates the receptors, therefore a net decrease in activation occurs and withdrawal develops 100 90 80 70 60 % 50 Mu Receptor Intrinsic 40 Activity 30 20 10 0 Full Agonist (e.g. heroin) A Net Decrease in Receptor Activity if a Partial Agonist displaces Full Agonist Partial Agonist (e.g. buprenorphine) no drug low dose DRUG DOSE high dose 2004, COMP meeting Receptor Affinity • AFFINITY is the strength with which a drug physically binds to a receptor Buprenorphine’s affinity is very strong and it will displace full agonists like heroin and methadone Note receptor binding strength (strong or weak), is NOT the same as receptor activation (agonist or antagonist) Mu Receptor Bup affinity is higher Full Agonist Bound to Receptor Therefore Full Agonist is displaced 2004, COMP meeting Receptor Dissociation DISSOCIATION is the speed (slow or fast) of disengagement or uncoupling of a drug from the receptor Buprenorphine’s dissociation is slow Therefore Buprenorphine stays on the receptor a long time and blocks heroin or methadone from binding Mu Receptor Bup dissociation is slow Therefore Full Agonists can’t bind 2004, COMP meeting Dose Response Methadone Simulated 24 Hr. Dose/Response At steady-state in tolerant patient “Loaded” “High” mmt bup Normal Range “Comfort Zone” heroin Subjective “Sick” w/d Objective w/d 0 hrs. Time 2004, COMP meeting Opioid Agonist Treatment of Addiction - Payte - 1998 24 hrs. Specific adjustments: Patient selection System to inform patients and answer questions about buprenorphine, fees, etc. Easier to move from bup to methadone than v.v. (ie, may want to use as first line) Pt has to taper to 30 of methadone to transfer. 2004, COMP meeting Specific adjustments: DATA 2000 option May set up separate billing and charts, if DATA 2000 is used Decision to order RX pads Scheduling of doc and counselor time Keep 30 patient census May use nurses to do pill counts May set up special fee structure. 2004, COMP meeting Specific adjustments: under OTP regs. Induction timing becomes critical What is observed dosing? May take up to 20 minutes, use waiting room more. How to monitor compliance: urine test for bup expensive, may do pill counts instead May want to do MWF dosing May ask for exception to daily observed dosing in some cases. Change DEA license to include schedule 3. 2004, COMP meeting Useful websites: CSAT physician locator by zip code: http://buprenorphine.samhsa.gov/bwns_lo cator/index.html CSAM: www.csam-asam.org. Has forms and handouts on website. ASAM’s capwiz for info on 30 patient limit bills pending. www.asam.org 2004, COMP meeting