Determining Appropriateness For Buprenorphine Treatment
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Several issues should be considered in evaluating whether a patient is an appropriate candidate for buprenorphine treatment of opioid addiction in the office or other setting.
First, a candidate for buprenorphine treatment for opioid addiction should have an objectively ascertained diagnosis of o opioid addiction (compulsive use of opioids despite harm), otherwise known as opioid dependence as defined in the latest edition of the DSM-IV-TR of the APA (2000). In rare instances, a patient may be physiologically dependent on opioids and meet DSM-IV-TR criteria for abuse, but not for dependence. In such a case, a short course of buprenorphine may be considered for detoxification. Maintenance treatment with buprenorphine is not recommended for patients who do not meet DSM -IV-TR criteria for opioid dependence.
Second, a candidate for buprenorphine treatment should, at a minimum
(1) Be interested in treatment for opioid addiction.
(2)Have no absolute contraindication (i.e., known hypersensitivity) to buprenorphine (or to naloxone if treating with the buprenorphine/naloxone combination).
(3)Be expected to be reasonably compliant with such treatment.
(4)Understand the risks and benefits of buprenorphine treatment.
(5)Be willing to follow safety precautions for buprenorphine treatment .
(6)Agree to buprenorphine treatment after a review of treatment options.
Patients who request treatment with buprenorphine to achieve abstinence from all illicit opioid use should be able to receive this treatment, if it is clinically indicated.
Cautions and Contraindications for Buprenorphine Treatment
Several medical conditions and medications, as well as concurrent abuse of other drugs and alcohol, necessitate caution or are relative contraindications to buprenorphine treatment.
Buprenorphine should be used cautiously in patients who are being treated for seizure disorders. When buprenorphine is used concurrently with antiseizure medications (e.g., phenytoin, carbamazepine, valproic acid, and others), metabolism of buprenorphine and/or the antiseizure medications may be altered. (See figure 2-3.) In addition, the relative risk of interaction between buprenorphine and sedative -hypnotics (e.g., phenobarbital, clonazepam) should be kept in mind. Monitoring for therapeutic plasma levels of seizure medications should be considered.
Buprenorphine should be used cautiously in combination with HIV antiretroviral medications that may inhibit, induce, or be metabolized by the cytochrome P450 3A4 enzyme system. (See figure 2-3.) Protease inhibitors inhibit cytochrome P450 3A4. Metabolism of buprenorphine and/or the antiretroviral medications may be altered when they are combined. In some cases, therapeutic blood levels may need to be monitored. Note that this is a caution, not a contraindication; successful treatment of addiction with buprenorphine in HIV-infected patients has been well demonstrated (Berson et al. 2001; Carrieri et al. 2000; McCance -Katz et al. 2001; Moatti et al. 2000).
Hepatitis and Impaired Hepatic Function
Pharmacotherapy with buprenorphine is not contraindicated on the basis of mildly elevated liver enzymes; however, elevated liver enzymes should be appropriately evaluated and monitored.Viral hepatitis (especially infection with HBV or HCV) is common among individuals who abuse opioids and should be evaluated and treated appropriately.
Buprenorphine is classified by FDA as a Category C agent. Very few studies exist on the use of buprenorphine in pregnant women. If a patient is pregnant or is likely to become pregnant during the course of treatment with buprenorphine, the physician must consider whether buprenorphine is the appropriate treatment and must weigh the risks and benefits of buprenorphine treatment against all the risks associated with continued heroin or other opioid use. In the United States, methadone is the standard of care for pregnant women who are addicted to opioids. (See "Pregnant Women and Neonates" )
Buprenorphine is a treatment for opioid addiction, not for addiction to other classes of drugs. Although the use of other drugs tends to be a predictor of poor adherence, other drug use is not an absolute contraindication to buprenorphine treatment. (See below for exceptions.)
Patients should be encouraged to abstain from the use of all nonprescribed drugs while receiving buprenorphine treatment. However, abuse of or dependence on other drugs (e.g., alcohol, cocaine, stimulants, sedative -hypnotics, hallucinogens, inhalants) is common among individuals who are addicted to opioids, and such abuse or dependence may interfere with overall treatment adherence.
Patients who use or abuse more than one substance present unique problems and may need referral to resources outside the office setting for more intensive treatment. Patients should be encouraged to be truthful about their use of all drugs. A recent drug use history and a toxicology screen for drugs of abuse are guides to help assess use, abuse, and dependence on opioids and other drugs. Treatment of patients with more than one addiction problem will depend largely on the physician's level of comfort in treating addiction, the availability of psychosocial support and counseling, and the availability of other forms of addiction treatment. (See "Polysubstance Abuse" in chapter 5.)
The use of sedative -hypnotics (benzodiazepines, barbiturates, and others) is a relative contraindication to treatment with buprenorphine because the combination (especially in overdose) has been reported to be associated with deaths ( Renaud et al.1998 a.,b). The combination of buprenorphine and sedative-hypnotics may increase depression of the central nervous system. If treatment with buprenorphine and sedative -hypnotics is necessary, the doses of both medications may need to be lowered. Physicians must assess for use, intoxication, and withdrawal from sedative-hypnotics. Unfortunately, the use of certain benzodiazepines and other sedatives may not be detected on routine drug screens. Physicians must determine their laboratory's specific parameters for detection of sedative -hypnotic use.
Because alcohol is a sedative -hypnotic drug, patients should be advised to abstain from alcohol while taking buprenorphine. Rarely are individuals with active, current alcohol dependence appropriate candidates for office-based buprenorphine treatment. (It may be possible to treat such patients through initial, intensive services that effectively detoxify the patient from alcohol while concurrently starting buprenorphine [e.g., in an inpatient or residential setting].)
Patients may present with withdrawal symptoms from other drugs at the same time they are experiencing opioid withdrawal symptoms. Buprenorphine will not control seizures caused by withdrawal from alcohol or other sedative -hypnotic substances. Benzodiazepines and barbiturates, the most commonly used pharmacological treatments for seizures caused by alcohol or other sedative-hypnotic withdrawal, should be used only with caution in combination with buprenorphine because of the increased risk of central nervous system and respiratory depression from the combination.
Patients who may be good candidates for opioid addiction treatment with buprenorphine are those who have an objective diagnosis of opioid addiction, who have the appropriate understanding of and motivation for buprenorphine treatment, and who do not have medical or psychiatric contraindications to this form of treatment. This chapter has provided information on the questions, cautions, and contraindications that should be considered when determining whether a patient is an appropriate candidate for opioid addiction treatment with buprenorphine.
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References: Clinical Guidelines For The Use Of Buprenorphine In The
Treatment of Opiate Addiction Chapter 3 Patient Assessment (TIP 40)
Compiled And Edited By: Deborah Shrira Updated: 20 March 2007