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Buprenorphine/Naloxone: Office-Based Opioid Dependence Treatment

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Buprenorphine/Naloxone: Office-Based Opioid Dependence Treatment November 29, 2013 Curtis Handford MD CCFP MHSc Dale Wiebe MD CCFP Addictions Program – PowerPoint PPT presentation

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Title: Buprenorphine/Naloxone: Office-Based Opioid Dependence Treatment


1
Buprenorphine/Naloxone Office-Based Opioid
Dependence Treatment
  • November 29, 2013
  • Curtis Handford MD CCFP MHSc
  • Dale Wiebe MD CCFP
  • Addictions Program

2
Faculty/Presenter Disclosure
  • Faculty Curtis Handford/Dale Wiebe
  • Program 51st Annual Scientific Assembly
  • Relationships with commercial interests
  • None

3
Disclosure of Commercial Support
  • No commercial support of this program
  • Potential for conflict(s) of interest
  • None

4
Mitigating Potential Bias
  • N/A

5
Acknowledgements
  • Psychopharmacology of Opioids Planning Group
  • DR. BERNARD LeFOLL MD, PhD, CCFP
  • University of Toronto/CAMH
  • DR. PETER SELBY MBBS, CCFP, FCFP, dip ABAM
  • University of Toronto/CAMH
  • DR. MARILYN HERIE PHD, MSW, RSW
  • University of Toronto/CAMH
  • ROSA DRAGONETTI MA, CAMH
  • WAYNE SKINNER MSW, University of Toronto/CAMH
  • ANDREA TSANOS MA, CAMH
  • CAMH Education Services
  • MS. GALIT KADIN
  • MS. ANNE SIMON

6
Objectives
  • By the end of the workshop you will be able to
  • List the benefits and describe pharmacology of
    buprenorphine/naloxone (Suboxone)
  • Demonstrate the key elements of
  • Diagnosis
  • Preparation
  • Induction
  • Maintenance
  • Cite the CAMH guideline (CPG) recommendations for
    the use of buprenorphine/naloxone.

7
Agenda
  • 130-140 Welcome and Introductions
  • 140-200 Diagnosis
  • 200-220 Mary video 1 and discussion
  • 220-245 Treatment options and Mary video 2
  • 245-315 Preparation and Induction
  • 315-330 Break
  • 330-400 Darrell/Nancy Induction Video and
    discussion
  • 400-420 Maintenance/Take homes/Urine Tox
  • 420-450 Darrell/Nancy take-home doses and
    discussion
  • 450-500 Wrap up and evaluations

8
Treatment Setting
9
Buprenorphine in Primary Care
  • Frances buprenorphine maintenance has largely
    been prescribed by primary care physicians.
  • 1994-1999, access to opioid dependence treatment
    increased (bupe 80, meth 20) and overdose
    deaths decreased significantly (79).Auriacombe
    et al. The American J on Addictions
    200413S17-28
  • Several studies demonstrate that buprenorphine
    can be used as effectively and safely in primary
    care when compared to specialty clinics.Gibson
    et al. Med J Australia 200317938-4

    OConner et. al. Am J Med 1998105100-105

10
CPG Recommendation 2
  • Buprenorphine/naloxone maintenance treatment can
    be prescribed to patients in either a primary
    care setting or in a specialized addiction
    treatment setting. I, A.
  • Intro p.12 Advisable for a physician or
    pharmacist with no experience in opioid
    maintenance treatment to complete a formal
    program (examples Appendix I)
  • Drug monograph Prescribers are to complete an
    accredited Suboxone education program
  • CPSO buprenorphine prescribing course observe

11
Diagnosis
12
CPG Recommendation 3
  • Prior to initiating maintenance opioid agonist
    treatment the patient should meet the diagnostic
    criteria for opioid dependence. III, A
  • Hard to interpret these DSM criteria in CNCP. Can
    be a challenging diagnosis to make in the chronic
    pain population. (Heit H and Gourlay D., 2009)
  • Canadian Opioid Guidelines are a resource to
    assist http//nationalpaincentre.mcmaster.ca/opio
    id/documents.html

13
Case 1 Background
  • Your patient of 5 years, John Doe, 25, arrives
    for an appt. one day and informs you he needs
    help for his addiction
  • He has been buying MSContin off the street for
    18 months, peeling and injecting them. He now
    uses 4x100 mg tabs per day
  • Flu-like symptoms if goes 12 hrs without

13
14
Case 1 Background
  • Spends all day worrying about how he is going to
    be able to get the money to pay for the pills
  • Lost girlfriend, job, house
  • Has tried to control his use, but he cant seem
    to reduce his dose at all

14
15
DSM-IV
  • Tolerance Yes
  • Withdrawal Yes
  • Time Spent Yes
  • Unsuccessful Attempts to D/C Yes
  • Given up activities ?
  • Used more than intended ?
  • Use despite consequences Yes

15
16
Case 1 The Issue
  • Diagnosis?
  • Opioid dependence
  • Plan?
  • Withdrawal mgmt and intensive psychosocial
    treatment
  • Buprenorphine/Naloxone
  • Methadone

16
17
Case 2 Background
  • Your patient, Jane Frank, 53, has been prescribed
    codeine Contin from you for the past 5 years to
    treat severe hip pain second to osteoarthritis
  • Her pain scales are usually 3/10. She is able to
    work as receptionist and garden/golf. No previous
    evidence of misuse of prescription

17
18
Case 2 Background
  • Jane walks into the office and anxiously informs
    you that she had got stuck out of town for a day
    and ran out of her codeine.
  • In that 24-hr period, she started to develop
    sneezing, generalized pain, nausea, sweats. This
    resolved after resuming codeine.
  • She is frightened and wants to know if she is
    addicted to her codeine.

18
19
DSM-IV
  • Tolerance Yes
  • Withdrawal Yes
  • Time Spent No
  • Unsuccessful Attempts to D/C No
  • Given up activities No
  • Used more than intended No
  • Use despite consequences No

19
20
Case 2 The Issue
  • Diagnosis?
  • Physical dependence
  • What do you advise her?
  • No evidence of opioid dependence
  • Physical dependence is an expected physiologic
    phenomenon. Does not equal addiction
  • Next steps?
  • Carry on
  • Perhaps try a slow taper if patient really
    concerned

20
21
Diagnosis Mary
  • Mary Video 2A
  • Q Which criteria of the criteria listed in the
    DSM-IV have you identified in Marys history?

22
Mary DSM-IV
  • Tolerance
  • Withdrawal
  • Time Spent
  • Unsuccessful Attempts to D/C
  • Given up activities
  • Used more than intended
  • Use despite consequences

22
23
Case 3 Mary
  • Diagnosis?
  • What do you advise her?
  • Next steps?

23
24
Prescribing Practices
  • Trial of Opioid Therapy in properly selected
    patients
  • Check the 5 As at every follow up visit (6-9
    wks)7
  • Analgesic effectiveness (pain scales)
  • Adverse Effects
  • Ability to function
  • Aberrant/Abuse behaviors (including substances)
  • Affect
  • If pain function consistently improved at
    reasonable dose, can carry on without need for
    consultation.

24
25
Prescribing Aberrant Behavior
  • High-risk abuse behaviors23,40
  • Many unsanctioned dose escalations
  • Frequent lost prescriptions
  • Concurrent abuse of related illicit drugs
  • Borrowing drugs from others/street
  • Injecting (tracks!), forgery, selling,
    double-doctoring

25
26
Prescribing Aberrant Behavior
  • Prevalence among chronic pain patients 11.5
  • Illicit drugs present in 14.5 of UDSs
  • No opioid or non-prescribed opioid in 20.4 of
    UDSs33

26
27
Prescribing Aberrant Behavior
  • Grounds for action!
  • Lesser behaviors should lead to more
    structured opioid therapy (SOT)
  • Tightening of the boundaries, UDT, ?addiction
    medicine referral
  • Watch for pseudoaddiction!
  • Pseudoaddiction will ameliorate with SOT

27
28
Diagnosing Opioid Dependence
  • Tolerance, withdrawal in and of themselves do not
    equal addiction
  • Acquiring significant amounts of opioids from
    other sources (other MDs, OTC, street)
  • Injecting or insufflating prescribed opioids
  • Failure to stabilize aberrant behavior with SOT
  • If appropriate
  • DSM IV-TR versus DSM V update
  • OAT for moderate to severe?

28
29
DSM IV-TRDependence vs. Abuse
  • Tolerance
  • Withdrawal
  • Time Spent
  • Unsuccessful attempts to D/C
  • Given up activities
  • Used more than intended
  • Use despite consequences
  • Failure to fulfill major role obligations
  • Use in hazardous situations
  • Legal problems
  • Social or interpersonal problems

30
DSM VSubstance Use Disorder
  • Tolerance (not counted if prescribed)
  • Withdrawal (not counted if prescribed)
  • Used more than intended
  • Cravings
  • Unsuccessful attempts to D/C
  • Time Spent
  • Given up activities
  • Use despite consequences
  • Failure to fulfill major role obligations
  • Use in hazardous situations
  • Social or interpersonal problems
  • Mild
  • 2 to 3 criteria
  • Moderate
  • 4 to 6 criteria
  • Severe
  • 7 to 11 criteria

31
Opioid Dependence Treatment Options
32
Withdrawal Management (Detox)
  • Evidence suggests that OAT outcomes superior to
    detox
  • Can be hazardous on discharge due to loss of
    tolerance
  • Most of OAT evidence from IV heroin users
  • Reasonable, with informed consent, for some
    patients to attempt detoxification
  • Patient preference
  • Exclusive PO opioid dependence
  • Young age
  • Brief duration of dependence
  • Solid social supports

33
Opioid Agonist Treatment OAT
  • Observational studies demonstrate reduced
    mortality for individuals on OAT compared to
    those off OAT.(Gronbladh L et. al.,
    1990)(Caplehorn JRM et al., 1994)
  • Reduced risky behaviour and decreased HIV
    seroconversion rates(Gowing et. al.,
    2008)(Metzger et al., 1993)

34
Opioid Agonist Treatment
  • Methadone and buprenorphine
  • Meta-analyses for both drugs confirm superiority
    to placebo in terms of retention in treatment and
    reduced illicit opioid use
  • Flex dose methadone appears marginally better in
    terms of treatment retention (RR 0.85,
    0.73-0.98).
  • Equivalent with respect to reducing illicit
    opioid use. (Mattick et. al., 2008)
  • ? Old evidence generalizable to oral prescription
    opioid dependent pts

35
Buprenorphine Safety
  • French population-level data 1994-1998 suggests
    that there is 3x less mortality due to
    buprenorphine than due to methadone. 46 rather
    than 288 deaths.
  • Auriacombe et al. JAMA 2001285(1)45
  • Post-mortem studies also suggest lower rate of
    overdose deaths involving buprenorphine compared
    to methadone.
  • Pirnay et al. Addiction 200499978-988
  • Soyka et al. Pharmacopsychiatry 20063985-87
  • Gibson et al. Drug and Alcohol Review
    200726405-410 (?underestimate of bupe deaths)
  • More OD symptoms with methadone than bupe
  • Nielson 2007 and Nielson 2008

36
Buprenorphine Safety
  • Bupe implicated in some OD deaths
  • Almost exclusively (116/117) in combo with other
    sedating substances.
  • Kintz et al. Forensic Science International
    200112165-69.
  • 7/43 bupe-alone deaths in UK 1980-2002
  • Schifano et al. Hum Psychopharmacol Clin Exp
    200520343-348
  • No difference in mortality b/w methadone and bupe
    gps
  • (Ling 1996, Gibson 2008, Soyka Apelt 2006)
  • Bupe more non-fatal heroin ODs than methadone
    (P0.08) DiGiusto 2004

37
Pharmacology of buprenorphine
38
Unique pharmacological properties
  • High affinity for opioid receptor (i.e. binds
    tightly), thus blocking the effect of other
    opioids.
  • Less risk of overdose and respiratory depression
    because it is a partial-agonist.
  • Long half-life, thus allowing less-than-daily
    dispensing and possibly easier withdrawal.(Gowing
    L, Ali R, White J. 2006).

39
Pharmacology Safety
Mu receptor analgesia, respiratory depression,
pupillary constriction, ?bowel mobility,
sedation Kappa receptor analgesia, dysphoria,
diuresis, ?addiction
  • Mu receptor partial agonist (turns partly on)
  • Ceiling effect for opioid agonist
    properties(Walsh SL et al. 1994)
  • Kappa receptor antagonist (turns off)
  • Could be what offsets the respiratory depression
    effect at higher doses
  • May account for decreased dysphoria observed in
    some studies(Johnson et al, 2003)

40
Route of Administration Pharmacokinetics
  • Available in Canada as sublingual tablet, takes a
    few minutes to dissolve. Film may be coming soon.
  • Rapid absorption by buccal mucosa, then slowly
    released into bloodstream (45 min-1.5 hr)
  • Peak plasma concentration in 1-4 hrs
  • Very low oral bioavailability due to first pass
    effect
  • Can be abused intravenously (reason for nlx) or
    intra-nasally
  • (Chiang CN et. al., 2003. Walsh SLW, et. al.,
    2003)

41
CPG Recommendation 10
  • Policy makers should be aware that in countries
    where buprenorphine is equally available as
    methadone, buprenorphine has a lower attributable
    death rate than methadone. II-3, A

42
CPG Recommendation 1
  • Once a patient is diagnosed with opioid
    dependence and is deemed appropriate for opioid
    agonist treatment, prescribers are encouraged to
    consider prescribing either buprenorphine/naloxone
    or methadone in order to increase retention in
    treatment and decrease opioid misuse. I, A

43
CPG Recommendation 4
  • The decision to initiate opioid agonist therapy
    with either buprenorphine/naloxone or methadone
    maintenance should be guided by the individual
    clinical circumstances and the patients
    preferences. III, I

44
CPG Recommendation 12
  • Buprenorphine/Naloxone may be preferred over
    methadone if
  • C/I to methadone allergy/QT risks (Level I)
  • Hx of sexual S/E or oversedation on methadone
    (Level II)
  • Increased risk of opioid toxicity (age, PMHx, BZ,
    meds (Level II))
  • Good prognostic factors (age, social, duration)
  • Past success with buprenorphine
  • Methadone unavailable in timely manner

45
Recommendation 13
  • Methadone may be preferred over
    buprenorphine/naloxone
  • Allergy to buprenorphine
  • Pregnancy (buprenorphine/naloxone specifically)
  • If induction withdrawal dangerous
  • Hx injecting buprenorphine
  • Prev inability to stabilize on buprenorphine
  • Prev success with methadone
  • Severe dry mouth
  • No reliable way to pay

46
Treatment Options Mary
  • Mary 2B
  • Q Now that Mary expressed her interest in
    maintenance treatment with a long-acting opioid,
    which medication do you think may be better for
    Mary? Is there a specific reason to choose one
    over the other?

47
Using Buprenorphine/naloxone
48
CPG Recommendation 6
  • Prior to initiation of buprenorphine/naloxone
    treatment, the patient must provide informed
    consent and there must be physician documentation
    that the patient has been informed of the
    physical dependence on the medication and
    possible long-term nature of the maintenance
    treatment. III A

49
Buprenorphine-Preparation
  • Diagnosis of opioid dependence
  • Urine Drug Test (UDT) positive for opioids (Sup
    4)
  • Contraindications?
  • Informed consent
  • Treatment options
  • Risks and benefits
  • Clarify goals and expectations
  • Establish coverage
  • Consider written treatment agreement (Appendix J)

50
Bup/Nlx Contraindications
  • Pregnancy (buprenorphine/naloxone specifically)
  • Allergy
  • Severe liver dysfunction
  • Acute severe respiratory illness
  • Decreased level of consciousness
  • Paralytic ileus
  • Inability to provide informed consent
  • Possibly elevated transaminases beyond 3-5 times
    ULN

51
Preparation
  • Investigations
  • ßHCG
  • Liver enzymes/LFTs
  • HIV/Hepatitis testing
  • Instructions for induction day
  • Present in withdrawal
  • D/C IR opioids 12 hrs, SR opioids 24 hrs
  • Do not drive

52
Formulary coverage
  • As of October 30, 2012, Suboxone is Limited Use
    in Ontario
  • LU code 437
  • Failed methadone
  • Intolerance
  • Contraindication (ie QT, allergy)
  • Higher risk for opioid toxicity
  • BZ, alcohol, p450 inhibitors, elderly, lower
    tolerance
  • LU code 438 methadone
  • maintenance program is not available or
    accessible gt3 mos

53
Induction
54
CPG Recommendation 5
  • A physician should have a structured approach,
    such as the one suggested in the clinical
    considerations, to initiating buprenorphine/naloxo
    ne maintenance treatment in order to stabilize a
    patient at their maintenance dose as rapidly as
    possible while at the same time avoiding
    oversedation or precipitated withdrawal. III, A

55
Buprenorphine - Induction
  • Patient must be in moderate opioid withdrawal
    before receiving the initial dose of bup/nlx
  • Estimated amount of time to wait after last use
  • Short-acting opioids 6h minimum, 12h preferable
  • E.g. heroin, oxycodone, hydromorphone, codeine
  • Longer-acting opioids 12h minimum, 24h
    preferable
  • OxyContin and other slow-release opioids that
    are chewed or crushed longer if swallowed whole
  • Methadone 24h minimum, 36h 3 days preferable

56
Buprenorphine - Induction
  • Suggest use COWS assessment tool (Appendix K)
  • If score lt13 (mild withdrawal), advisable to wait
    until next day or reassess in 2-4 hours
  • If 13, initiate dosing
  • 2 mg dose if
  • at higher risk for opioid toxicity
  • not completely certain the patient is in moderate
    withdrawal
  • transferring from methadone
  • 4 mg for patients clearly in withdrawal at
    lower risk for opioid toxicity

COWSClinical Opiate Withdrawal Scale
57
Buprenorphine-Induction
  • Consider reassessment at 1hr to assess for
    precipitated withdrawal (p/w).
  • If p/w, do not give an additional dose of
    buprenorphine/naloxone
  • Consider reassessment at 3hrs to assess need for
    additional dose(s).
  • Can provide additional 2mg doses on day 1 (to a
    max of 8mg on day 1).
  • Observed or take-home
  • Return to clinic next 1-3 days for possible dose
    increase.

58
Precipitated Withdrawal What Is It?
  • Buprenorphine preferentially binds to the opioid
    receptor, but only partially activates it
  • Abrupt onset of withdrawal symptoms within 1 hour
    of taking buprenorphine dose sxs peak 1.5-3hrs
  • May take up to 12 hours to resolve
  • Management is symptomatic
  • Additional doses will worsen symptoms

59
Precipitated Withdrawal
Precipitated Withdrawal Relative to intoxication,
Suboxone turns on receptors less ? patient
feels withdrawal
Buprenorphine Binds preferentially to
receptors Volume on medium
Intoxication Significant amount of opioid bound
to receptors Volume on max
Induction Relative to withdrawal, Suboxone
turns on receptors more ? patient feels better
Buprenorphine Binds preferentially to
receptors Volume on medium
Withdrawal Most receptors unbound Volume on low
60
Induction Darrell
  • Q How would you define the state of Darrells
    withdrawal? How do you suggest to proceed
  • Q How could this have been prevented?

61
Buprenorphine - Titrating dose
Dose
Maximum recommended daily dose (according to Canadian Product Monograph) 24 mg
Dose can be increased daily or every 2-3 days by 2-4 mg
Average maintenance dose range 8-12 mg/day
62
Induction
  • Faster inductionbetter retention(Compton P et
    al. 1996) (Doran C et al. 2005)
  • Monitor for opioid toxicity
  • Collateral hx valuable if available
  • Induction is a balance between
  • Buprenorphines dynamics Ceiling effect of
    partial agonist
  • Buprenorphines kinetics Long half-life of 24-36
    hrs

63
Induction
  • Maintenance dose should be reached within a
    couple of weeks
  • No opioid withdrawal symptoms for 24hrs
  • Reduction in cravings
  • No reinforcing effect from opioids

64
Induction Nancy
  • Q What is your interpretation of Nancys
    disclosure? How would you like to respond?
  • Q Based on the information Nancy has thus far
    provided, will you increase her bup/nlx dose? By
    how much? For how many days will you prescribe
    the new dose?
  • Q Would you increase the dose at this point? How
    much?

65
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66
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67
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68
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69
Take-home doses
70
CPG Recommendation 9
  • In making decisions regarding the provision of
    take-home doses of buprenorphine/naloxone,
    providers should use a clinical risk
    stratification strategy (as described in the
    clinical considerations) that aims to support
    patient autonomy while at the same time
    respecting patient and public safety. III, A

71
Buprenorphine/Nlx - Take-home doses
  • Health Canada Product Monograph
  • Require buprenorphine be prescribed daily
    observed for 2 months, except for weekends and
    holidays (if pharmacy closed)
  • No evidence identified supporting this for
    buprenorphine/naloxone
  • When deciding about take-home doses assess
  • Is it safe for the patient?
  • Is it safe for the public?
  • What is the risk of diversion?

72
Take-home doses Early in treatment 3 categories
  • Too unstable to have any take-homes, including
    weekends and holidays
  • Recent IV drug use
  • Recent suicidal ideation
  • Significant cognitive impairment
  • Unstable housing
  • Ongoing opioid use
  • Other active alcohol or drug dependencies
  • Concern NYD

73
Take-home doses Early in treatment 3 categories
  • Appropriate to provide weekend and holiday
    take-homes
  • No recent IV drug use
  • No recent suicidality
  • No signifiant cognitive impairment
  • Stable housing
  • Achieved abstinence from opioids
  • No other active alcohol or drug dependencies
  • No concern NYD

74
Take-home dosesEarly in treatment 3 categories
  • Appropriate accelerated take-home doses beyond
    weekends and holidays within the first 2
    months
  • Clinical stability beyond category 2
  • No significant psychiatric co-morbidity
  • Particularly stable social situation
  • Overly restrictive take-home dosing may lead to
    treatment drop out due to work conflicts.

75
Take-home doses
  • If providing accelerated take homes
  • Consider other options first
  • EOD dosing, pharmacy change
  • Discuss with the patient the risks of these
    accelerated take-homes
  • Monitor closely to ensure benefit
  • Document carefully

76
Take-home doses
  • Number of take-home doses per week increases
    gradually
  • Suggested maximum of 6-13 consecutive take-home
    doses, dispensed between observed doses.
  • If relapse to problematic drug use or compromised
    clinical stability
  • More frequent visits and UDS
  • Increased number of witnessed doses

77
Take-Home Doses Darrell and Nancy
  • Q Are there any circumstance under which you
    will consider to give take-home doses during the
    first week of treatment with buprenorphine?
  • Q What do you want to do with her bup/nlx
    treatment?
  • Q What do we look for to determine clinical
    stability?
  • Q When would you consider re-instituting take
    home doses?

78
Take-home doses Safety
  • Injection abuse
  • Plenty of evidence that buprenorphine monoproduct
    is injected (Obadia 2001, Vidal-Trecan 2003).
  • Much more than methadone (Barrau 2001).
  • Evidence that bup/nlx is pleasurable to
    non-dependent users (Strain 2000, Weinhold 1992)
  • IV Bup/nlx pleasurable in bup/nlx maintained
    subjects (Bell 2007)
  • Case reports of hepatotoxicity if abused IV
    (Herve 2004)

79
Buprenorphine/Naloxone Injection
  • Naloxone was introduced to deter IV use
  • Naloxone
  • opioid receptor antagonist
  • binds opioid receptor, but no intrinsic activity
  • precipitates withdrawal in clients physically
    dependent on opioids
  • little to no sublingual or oral bioavailability
  • deterrent only when used IV
  • (Chiang, NC, 2003.)

80
Buprenorphine/Naloxone Injection
  • But naloxone
  • only partially blocks opioid receptor binding
  • has much shorter duration of action than
    buprenorphine
  • Combo product is abused despite deterrent effect

81
Missed doses
82
Buprenorphine - Missed doses
  • Missed 5 days may resume their usual dose
  • Missed gt 5 consecutive days MD should reassess
    before restarting
  • New dose can be titrated upwards by 2-4 mg/day

Usual dose Number of consecutive days missed New starting dose
gt 8 mg gt 7 days 4 mg
gt 8 mg 6-7 days 8 mg
6-8 mg 6 or more days 4 mg
2-4 mg 6 or more days 2-4 mg
Lintzeris et. al. Commonwealth of Australia, 2006
83
Urine Drug Testing (UDT)
  • CPG Recommendation 8 When monitoring a patient
    on buprenorphine/naloxone maintenance, the
    physician should adopt a patientcentred urine
    drug testing strategy that maximizes clinical
    utility while avoiding testing without
    indication. III, I
  • Guideline Supplement 4
  • OAML March/Aug 2013 Memos (Handouts)
  • On-line urine toxicology resourcehttp//www.udtm
    onograph.com/

84

http//www.udtmonograph.com/
85
Urine toxicology
  • Enzyme immunoassay (EIA)
  • Lab or point-of-care (PoC)
  • Quick results
  • Sensitive, not specific
  • Mostly classes of drugs
  • Window 3-5 days most substances
  • Chromatography (GC/MS or LC/MS)
  • Lab only
  • Slower results
  • Specific
  • Individual substances
  • Shorter window of detection (1-3 days)

86
Urine toxicology
  • Ordering with Community Labs
  • Drugs of Abuse Screen
  • EIA opioids, cocaine, BZ, barbs, THC
  • Broad spectrum urine toxicology
  • Chromatography
  • Since Sep 2013 LC/MS/MS
  • Please look for.

87
c/o Gamma Dynacare
88
c/o Gamma Dynacare
89
Urine toxicology
  • Not as straightforward as it might seem!
  • Opiate EIA
  • Natural Opiates (ie morphine)
  • Semi-synthetic (ie oxycodone)
  • Synthetic (ie fentanyl)
  • Cross-reactions
  • Cut-offs
  • Supervised collection/temp. testing
  • Dilute samples
  • Call the lab if unexpected result!

90
Opioid Maintenance Tapering
  • Long term treatment, so almost always
    patient-driven.
  • Principles of support during taper
  • Frequent clinic visits
  • Supportive counseling
  • Pace of the taper determined by client except in
    rare cases of involuntary discharge.
  • Clonidine, NSAIDs, loperamide as adjuncts near
    end of taper.

91
Buprenorphine Tapering
  • Withdrawal may be less prolonged and severe than
    for methadone
  • Maybe delayed in onset
  • Taper slowly (e.g. 2mg per week)

92
Opioid Maintenance Tapering (contd)
  • Put taper on hold or increase dose if
  • severe withdrawal symptoms
  • drug cravings
  • drug use
  • Detoxification fear client may be fearful of
    life without safety net of medication and program
    support, especially near end of taper
  • Important to offer support post-taper and
    facilitate return to opioid maintenance treatment
    if relapse

93
Buprenorphine Overdose
  • Signs sedation, hypotension, pinpoint pupils,
    respiratory depression
  • Low risk overdose unless combined with other CNS
    depressants
  • Medical emergency need hospital monitoring
  • Primary management should be protection of airway
  • Naloxone may not be effective
  • higher doses than usual recommended to increase
    the probability that naloxone will preferentially
    bind opioid receptor vs. buprenorphine

94
Summary
  • Buprenorphine/naloxone is an evidence-based
    maintenance treatment for opioid dependence
  • Evidence for efficacy and safety in primary care
    settings
  • Partial mu properties reduces overdose risk
  • Office-based physicians can
  • Diagnose
  • Induct
  • Maintain
  • Take-home doses are contingent on clinical
    stability
  • Urine drug testing is an important aspect of this
    work

95
Resources
  • CAMH Bup/Nlx on-line course (early 14)
  • CAMH ODT core course
  • Jan 9-Feb 9/14
  • Feb 15-Mar 15/14
  • Mar 27-Apr 27/14
  • Addiction Medicine Service at CAMH
  • Self-refer 416-535-8501 x 36019
  • CAMH MD Referral F 416-595-6821
  • Addiction Clinical Consult Service (ACCS)
  • Tel 416 595-6968 or toll free 1 888 720-2227.
  • Hours 800 a.m. to 400 p.m., Monday to Friday.

96
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