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CORK Bibliography: Buprenorphine

44 citations. January 2010 to present

Prepared: June 2011

Aalto M; Halme J; Visapaa JP; Salaspuro M. Buprenorphine misuse in Finland. (letter). Substance Use & Misuse 42(6): 1027-1028, 2007. (3 refs.)

Azimi-Bolourian S; Fornili K. Buprenorphine: A Guide for Nurses (Technical Assistance Publication). Journal of Addictions Nursing 21(4): 183-186, 2010. (3 refs.)

Nurses working in opioid treatment programs (OTPs) and office-based community settings have essential roles in the assessment, screening, treatment monitoring and counseling of patients receiving buprenorphine for the treatment of opioid addiction. However, challenges to implementing buprenorphine treatment with patients addicted to opioids or other drugs, including medication diversion and confidentiality issues, require nurses to improve their professional skills and prepare themselves for the implementation of best practices in addiction settings. Recent studies have found that inconsistency between science and practice is often attributed to inadequate staff education and training. Nurses working in addiction settings have reported, on an ongoing basis, attending very few clinical trainings in the area of substance abuse. This guide highlights the addiction management skills of nurses and promotes a mutually respectful team environment in which nurses and physicians collaboratively work to improve the care provided to opioid addicted individuals, including assessment, induction, stabilization, maintenance, monitoring, addiction counseling and relapse prevention services. It also serves as a resource to help nurses working with community/office based physicians to improve treatment outcomes for individuals receiving office-based treatment for opioid addiction.

Baker J; Rainey PM; Moody DE; Morse GD; Ma Q; McCance-Katz EF. Interactions between buprenorphine and antiretrovirals: Nucleos(t)ide reverse transcriptase inhibitors (nrti) didanosine, lamivudine, and tenofovir. American Journal on Addictions 19(1): 17-29, 2010. (44 refs.)

To improve outcomes among injection drug users with HIV and/or chronic hepatitis B, it is important to identify drug interactions between antiretroviral and opiate therapies. We report the results of a study designed to examine the interaction between buprenorphine and the nucleos(t)ide reverse transcriptase inhibitors (NRTI) didanosine (ddI), lamivudine (3TC), and tenofovir (TDF). Opioid-dependent, buprenorphine/naloxone-maintained, HIV-negative volunteers (n = 27) participated in two 24-hour sessions to determine (1) pharmacokinetics of buprenorphine alone and (2) pharmacokinetics of both buprenorphine and either ddI, 3TC, or TDF. Among buprenorphine/naloxone-maintained study participants, no significant changes in buprenorphine pharmacokinetics were observed following ddI, 3TC, or TDF administration. Buprenorphine had no significant effect on NRTI concentrations. Concomitant use of buprenorphine with ddI, 3TC, or TDF results in neither a significant pharmacokinetic nor pharmacodynamic interaction.

Boyer EW; McCance-Katz EF; Marcus S. Methadone and buprenorphine toxicity in children. (review). American Journal on Addictions 19(1): 89-95, 2010. (31 refs.)

Recent years have seen very large increases in the prescribing of methadone and buprenorphine formulations for treatment of opioid addiction as well as the increasing utilization of methadone for the treatment of chronic pain. Coincident with the rise in the prescribing of these drugs has been a substantial increase in pediatric opioid toxicities and adverse events. This review will address the current state of methadone- and buprenorphine-related adverse events in children in the United States. We will also discuss treatment of opioid toxicity in pediatric populations and make recommendations aimed at reducing these occurrences.

Carrieri MP; Roux P; Cohen J; Ravaux I; Dellamonica P; Protopopescu C et al. Self-reported side effects in buprenorphine and methadone patients receiving antiretroviral therapy: Results from the MANIF 2000 cohort study. Addiction 105(12): 2160-2168, 2010. (43 refs.)

Aims: The aim of the study was to investigate the relationship between methadone and buprenorphine treatment and self-reported symptoms in HIV-infected opioid dependent individuals receiving antiretroviral therapy (ART). Design: Longitudinal study. Setting: The French MANIF2000 cohort was used to compare self-reported symptoms in buprenorphine and methadone patients also receiving ART. Participants: We selected individuals receiving ART and OAT (342 visits among 106 patients). Measurements: Symptoms were self-reported using a list of 14 symptoms (e.g. nausea, fatigue, fever) perceived during the previous 4 weeks, including three painful symptoms (abdominal or muscular pain, headaches). A two-step Heckman approach enabled us to account for the non-random assignment of OAT: a probit model identified predictors of starting either buprenorphine or methadone. A Poisson regression based on generalized estimating equations (GEE) was then used to identify predictors of the number of symptoms while adjusting for the non-random assignment of OAT. Findings: The median (interquartile range) number of symptoms was 4 (1-6) and 2 (1-6) among buprenorphine and methadone patients, respectively. After adjustment for non-random assignment of OAT type, depressive and opioid withdrawal symptoms, anxiolytics consumption and daily cannabis use, methadone patients were more likely to report a lower number of symptoms than those receiving buprenorphine. Conclusions: Methadone patients on ART report fewer symptoms than buprenorphine patients on ART under current treatment conditions in France. Further experimental research is still needed to identify an OAT-ART strategy which would minimize the burden of self-reported symptoms and potential interactions, while assuring sustainability and response to both treatments.

Comer SD; Sullivan MA; Vosburg SK; Manubay J; Amass L; Cooper ZD et al. Abuse liability of intravenous buprenorphine/naloxone and buprenorphine alone in buprenorphine-maintained intravenous heroin abusers. Addiction 105(4): 709-718, 2010. (40 refs.)

Background: Sublingual buprenorphine is an effective maintenance treatment for opioid dependence, yet intravenous buprenorphine misuse occurs. A buprenorphine/naloxone formulation was developed to mitigate this misuse risk. This randomized, double-blind, cross-over study was conducted to assess the intravenous abuse potential of buprenorphine/naloxone compared with buprenorphine in buprenorphine-maintained injection drug users (IDUs). Methods: Intravenous heroin users (n = 12) lived in the hospital for 8-9 weeks and were maintained on each of three different sublingual buprenorphine doses (2 mg, 8 mg, 24 mg). Under each maintenance dose, participants completed laboratory sessions during which the reinforcing and subjective effects of intravenous placebo, naloxone, heroin and low and high doses of buprenorphine and buprenorphine/naloxone were examined. Every participant received each test dose under the three buprenorphine maintenance dose conditions. Results: Intravenous buprenorphine/naloxone was self-administered less frequently than buprenorphine or heroin (P < 0.0005). Participants were most likely to self-administer drug intravenously when maintained on the lowest sublingual buprenorphine dose. Subjective ratings of 'drug liking' and 'desire to take the drug again' were lower for buprenorphine/naloxone than for buprenorphine or heroin (P = 0.0001). Participants reported that they would pay significantly less money for buprenorphine/naloxone than for buprenorphine or heroin (P < 0.05). Seven adverse events were reported; most were mild and transient. Conclusions: These data suggest that although the buprenorphine/naloxone combination has intravenous abuse potential, that potential is lower than it is for buprenorphine alone, particularly when participants received higher maintenance doses and lower buprenorphine/naloxone challenge doses. Buprenorphine/naloxone may be a reasonable option for managing the risk for buprenorphine misuse during opioid dependence treatment.

Daulouede JP; Caer Y; Galland P; Villeger P; Brunelle E; Bachellier J et al. Preference for buprenorphine/naloxone and buprenorphine among patients receiving buprenorphine maintenance therapy in France: A prospective, multicenter study. Journal of Substance Abuse Treatment 38(1): 83-89, 2010. (18 refs.)

Maintenance treatment with buprenorphine tablets (Subutex) has been associated with reductions in heroin use; however, concerns for intravenous misuse exist. A buprenorphine/naloxone formulation (Suboxone) was designed to reduce this misuse risk while retaining buprenorphine's efficacy and safety. This prospective, open-label, multicenter trial compared preferences for buprenorphine and buprenorphine/naloxone in 53 opioid-dependent patients stabilized on buprenorphine. Buprenorphine was first administered at the patient's current dose (Days 1-2), followed by a direct switch to buprenorphine/naloxone (Days 3-5). Global satisfaction rates were high and similar between buprenorphine and buprenorphine/naloxone; however, patients preferred the tablet taste, size, and sublingual dissolution time of buprenorphine/naloxone. At the end of the study, 54% of patients preferred buprenorphine/naloxone, 31% preferred buprenorphine, and 15% had no preference; most patients (71%) wished to continue treatment with buprenorphine/naloxone. This study did not identify any impediments to a direct buprenorphine-to-buprenorphine/naloxone switch and revealed some characteristics that may facilitate treatment with buprenorphine/naloxone.

DeMaria PA; Sterling RC; Risler R; Frank J. Using buprenorphine to treat opioid-dependent university students: Opportunities, successes, and challenges. Journal of Addiction Medicine 4(4): 236-242, 2010. (25 refs.)

Objective: The objective of this study was to characterize a population of opioid-dependent university students who were treated with buprenorphine, describe their treatment outcome, and discuss challenges the authors faced in working with this population in the setting of a university counseling center. Methods: We conducted a retrospective chart review of 27 opioid-dependent university students treated with buprenorphine at the university's counseling center. Results: Students were predominantly white (85%, n = 23), male (63%, n = 17), average age of 22 years with an average of 33.4 +/- 28.79 months (range = 4 to 132) opioid use before presentation. By self-report, 17 (63.0%) students reported heroin use, 9 (33.3%) students reported prescription opioid use, and 1 (3.7%) student reported use of both. Fifteen (56%) reported intravenous use. Treatment retention was high with students receiving an average of 12.00 + 11.49 months treatment (range = 1 to 36). During the course of treatment, 81% of all submitted urine drug screens were negative for opioids, 83.1% were negative for cocaine, 90.7% were negative for illicit (nonprescribed) benzodiazepines, and 59.1% were negative for marijuana. The average buprenorphine dose was 13.8 +/- 5.69 mg (range = 4 to 24 mg). No serious adverse effects occurred. In working with this population, we found that continued marijuana use, engagement in treatment, financial concerns, and decision making around family involvement were ongoing challenges. Conclusions: Opioid-dependent university students are a unique group of substance users. Our results indicate that they can be safely and effectively treated with buprenorphine in a university counseling center.

Ferrant O; Papin F; Clinic B; Lacroix C; Saussereau E; Remoue JE et al. Fatal poisoning due to snorting buprenorphine and alcohol consumption. Forensic Science International 204(1-3): E8-E11, 2011. (24 refs.)

High dosage buprenorphine (Subutex (R)) has been prescribed as a replacement therapy for major opioid dependencies in France since 1996. However, several studies have underlined its lethal risk, especially when administered intravenously, or when combined with benzodiazepines, alcohol or other central nervous system depressants. We report three fatal buprenorphine-related poisonings after snorting, among outside protocol individuals, observed at the Forensic Medicine Unit of Caen University Hospital. Medico-legal autopsies and complementary examinations were performed. The results are presented and discussed. Lethal poisoning after snorting buprenorphine was considered the most probable cause of death. These observations illustrate the risk of fatal poisoning by buprenorphine per-nasal route, which has rarely been reported in the literature although snorting is particularly prized by individuals outside the substitution therapy. We also observed the combination of buprenorphine and alcohol. By evaluating the pharmacological characteristics of this substance, as well as the data previously published in the literature, we have attempted to explain the pathophysiological mechanisms of this particular mode of poisoning that can easily be fatal.

Fokina VM; Patrikeeva SL; Zharikova OL; Nanovskaya TN; Hankins GVD; Ahmed MS. Transplacental transfer and metabolism of buprenorphine in preterm human placenta. American Journal of Perinatology 28(1I): 25-32, 2011. (27 refs.)

We sought to determine whether gestational age affects the transplacental transfer and metabolism of buprenorphine (BUP). Transfer of BUP (10 ng/mL) and its [ 3 H]isotope was determined across placentas of 30 to 34 weeks of gestation utilizing the technique of dual perfusion of placental lobule. Concentration of the drug in trophoblast tissue and in maternal and fetal circuits was determined by liquid scintillation spectrometry. Microsomes prepared from placentas of 17 to 37 weeks of gestation were divided into three groups: late second, early third, and late third trimesters. Antibodies raised against human cytochrome P450 (CYP) isoforms were utilized to identify the enzyme(s) catalyzing BUP biotransformation by preterm placental microsomes. The amount of norbuprenorphine formed was determined by liquid chromatography-mass spectrometry (LC-MS). BUP transfer across the placentas of 30 to 34 weeks of gestation was similar to those at term. CYP19 antibodies caused 60% inhibition of BUP metabolism by microsomes of late second and early third trimesters and 85% by microsomes of late third trimester. The developmental changes occurring in human placenta between 30 weeks of gestation through term do not affect the transfer of BUP across human placenta. CYP19 is the major enzyme responsible for biotransformation of BUP beginning at 17 weeks of gestation until term.

Gordon A; Callaghan D; Spink D; Cloutier C; Dzongowski P; O'Mahony W et al. Buprenorphine transdermal system in adults with chronic low back pain: A randomized, double-blind, placebo-controlled crossover study, followed by an open-label extension phase. Clinical Therapeutics 32(5): 844-860, 2010. (49 refs.)

Background: Buprenorphine is a mixed-activity, partial p-opioid agonist. Its lipid solubility makes it well suited for transdermal administration. Objective: This study assessed the efficacy and safety profile of a 7-day buprenorphine transdermal system (BIDS) in adult (age >18 years) patients with moderate to severe chronic low back pain previously treated with tablet daily of an opioid analgesic. Methods: This was a randomized, double-blind, placebo-controlled crossover study, followed by an open-label extension phase. After a 2- to 7-day washout of previous opioid therapy, eligible patients were randomized to receive BTDS 10 mu g/h or matching placebo patches. The dose was titrated weekly using 10- and 20-mu g/h patches (maximum, 40 mu g/h) based on efficacy and tolerability. After 4 weeks, patients crossed over to the alternative treatment for another 4 weeks. Patients who completed the double-blind study were eligible to enter the 6-month open-label phase. Rescue analgesia was provided as acetaminophen 325 mg to be taken as 1 or 2 tablets every 4 to 6 hours as needed. The primary outcome assessments were daily pain intensity, measured on a 100-mm visual analog scale (VAS), from no pain to excruciating pain, and a 5-point ordinal scale, from 0 = none to 4 = excruciating. Secondary outcome assessments included the Pain and Sleep Questionnaire (100-mm VAS, from never to always), Pain Disability Index (ordinal scale, from 0 = no disability to 11 = total disability), Quebec Back Pain Disability Scale (categorical scale, from 0 = no difficulty to 5 = unable to do), and the 36-item Short Form Health Survey (SF-36). Patients and investigators assessed overall treatment effectiveness at the end of each phase; they assessed treatment preference at the end of double-blind treatment. After implementation of a precautionary amendment, the QTc interval was measured 3 to 4 days after randomization and after any dose adjustment. All assessments performed during the double-blind phase were also performed every 2 months during the open-label extension. Adverse events were collected by non-directed questioning throughout the study. Results: Of 78 randomized patients, 52 (66.7%) completed at least 2 consecutive weeks of treatment in each study phase without major protocol violations (per-protocol [PP] population: 32 women, 20 men; mean [SD] age, 51.3 [11.4] years; mean weight, 85.5 [19.5] kg; 94% white, 4% black, 2% other). The mean (SD) dose of study medication during the last week of treatment was 29.8 (12.1) mu g/h for BTDS and 32.9 (10.7) mu g/h for placebo (P = NS). During the last week of treatment, BTDS was associated with significantly lower mean (SD) pain intensity scores compared with placebo on both the VAS (45.3 [21.3] vs 53.1 [24.3] mm, respectively; P = 0.022) and the 5-point ordinal scale (1.9 [0.7] vs 2.2 [0.8]; P = 0.044). The overall Pain and Sleep score was significantly lower with BTDS than with placebo (177.6 [125.5] vs 232.9 [131.9]; P = 0.027). There were no treatment differences on the Pain Disability Index, Quebec Back Pain Disability Scale, or SF-36; however, BTDS was associated with significant improvements compared with placebo on 2 individual Quebec Back Pain Disability Scale items (get out of bed: P = 0.042; sit in a chair for several hours: P = 0.022). Of the 48 patients/physicians in the PP population who rated the effectiveness of treatment, 64.6% of patients (n = 31) rated BTDS moderately or highly effective, as did 62.5% of investigators (n = 30). Among the 50 patients in the PP population who answered the preference question, 66.0% of patients (n = 33) preferred the phase in which they received BTDS and 24.0% (n = 12) preferred the phase in which they received placebo (P = 0.001), with the remainder having no preference; among investigators, 60.0% (n = 30) and 28.0% (n = 14) preferred the BTDS and placebo phases, respectively (P = 0.008), with the remainder having no preference. The mean placebo-adjusted change from baseline in the QTc interval ranged from -0.8 to +3.8 milliseconds (P = NS). BIDS treatment was associated with a significantly higher frequency of nausea (P < 0.001), dizziness (P < 0.001), vomiting (P = 0.008), somnolence (P = 0.020), and dry mouth (P = 0.003), but not constipation. Of the 49. patients completing 8 weeks of double-blind treatment, 40(81.6%) entered the 6-month, open-label extension study and 27 completed it. Improvements in pain scores achieved during the double-blind phase were maintained in these patients. Conclusions: In the 8-week, double-blind portion of this study, BIDS 10 to 40 mu g/h was effective compared with placebo in the management of chronic, moderate to severe low back pain in patients 11 had previously received opioids. The improvements in pain scores were sustained throughout the 6-month, open-label extension.

Gunderson EW; Wang XQ; Fiellin DA; Bryan B; Levin FR. Unobserved versus observed office buprenorphine/naloxone induction: A pilot randomized clinical trial. Addictive Behaviors 35(5): 537-540, 2010. (31 refs.)

Physician adoption of buprenorphine treatment of opioid dependence may be limited in part by concerns regarding the induction process. Although national guidelines recommend observed induction, some physicians utilize unobserved induction outside the office. The aim of this pilot randomized clinical trial was to assess preliminary safety and effectiveness of unobserved versus observed office buprenorphine/naloxone induction among patients entering a 12-week primary care maintenance study. Participants (N = 20) with DSM-IV opioid dependence were randomly assigned to unobserved or office induction, stratifying by past buprenorphine use. All patients received verbal and written instructions. A withdrawal scale was used during initiation and to monitor treatment response. Clinic visits occurred weekly for 4 weeks then decreased to monthly. The primary outcome, successful induction one week after the initial clinic visit, was defined as retention in buprenorphine/naloxone treatment and being withdrawal free. Secondary outcomes included prolonged withdrawal beyond 2 days after medication initiation and stabilization at week 4, defined as being in treatment without illicit opioid use for the preceding 2 weeks. Outcome results were similar in the two groups: 6/10 (60%) successfully inducted in each group, 3/10 (30%) experienced prolonged withdrawal, and 4/10 (40%) stabilized by week 4. These pilot study results suggest comparable safety and effectiveness of unobserved and office induction and point toward utilization of non-inferiority design during future definitive protocol development. By addressing an important barrier for physician adoption, further validation of the unobserved buprenorphine induction method will hopefully lead to increased availability of effective opioid dependence treatment.

Harrington CJ; Zaydfudim V. Buprenorphine maintenance therapy hinders acute pain management in trauma. American Surgery 76(4): 397-399, 2010. (8 refs.)

Buprenorphine is a mixed opiate receptor agonist-antagonist growing in popularity as an office-based treatment for opioid-dependent patients. It has high affinity, but only partial agonism at the R-opioid receptor resulting in a ceiling analgesic effect. At higher doses, buprenorphine potentiates antagonism at the kappa-opioid receptor. These properties make buprenorphine an effective maintenance treatment for opioid-dependent patients. These same properties, however, can interfere with the management of acute pain in patients on maintenance buprenorphine therapy. We present a case of a young multisystem trauma patient in whom adequate analgesia could not be achieved due to buprenorphine treatment before and through the early course of admission. Discontinuation of buprenorphine allowed for appropriate pain management and successful analgesia. Further education of acute care clinicians about buprenorphine pharmacology and careful selection of patients for buprenorphine maintenance therapy are needed to avoid delays of pain control in trauma patients.

Hillhouse M; Domier CP; Chim D; Ling W. Provision of ancillary medications during buprenorphine detoxification does not improve treatment outcomes. Journal of Addictive Diseases 29(1): 23-29, 2010. (21 refs.)

For individuals dependent on opioids, recovery efforts begin with a period of withdrawal that typically includes discomfort from symptoms, possibly precipitating a return to drug use. The study described here investigated whether the provision of ancillary medications for opioid withdrawal symptoms affected treatment outcomes in 139 participants receiving buprenorphine in a 13-day detoxification trial. Outcome measures include the number of opioid-free urine samples collected and retention in treatment. Ancillary medications were provided to 70% of participants: 59% received medication for insomnia, 45% for anxiety, 40% for bone pain, 35% for nausea, and 28% for diarrhea. Findings: indicate no difference in the number of opioid-free urine samples between the group receiving ancillary medication and the group who did not, although tests of specific ancillary medications indicate that those who received diarrhea medication had fewer opioid-free urines than those who did not (P = .004). Results also indicate that participants attended fewer days of treatment if they received anxiety, nausea, or diarrhea medication compared to no medication (all P values < .05).

Iversen J; Wand H; Gonnermann A; Maher L. Gender differences in hepatitis C antibody prevalence and risk behaviours amongst people who inject drugs in Australia 1998-2008. International Journal of Drug Policy 21(6): 471-476, 2010. (45 refs.)

Background: Global prevalence of hepatitis C virus (HCV) is estimated to be around 3% with approximately 170 million people affected. In Australia, and in many other resource rich countries, injecting drug use is the single most important risk factor for acquiring HCV, with around a third of diagnoses occurring in women. This study aims to assess gender differences in hepatitis C antibody prevalence and associated risk behaviours amongst a large sample of PWID in Australia. Methods: During a one to two week period in October, PWID attending selected NSP sites are invited to participate in the Australian NSP Survey. Between 1998 and 2008, approximately 16,000 individuals completed a self-administered questionnaire and provided a capillary blood sample for HIV and HCV antibody testing. We stratified our sample by time since onset of injecting and analysed the demographic characteristics, injecting behaviours and antibody test results to determine gender differences. Results: Women were found to be at increased risk of exposure to hepatitis C in all duration of injection categories except those injecting for 17 or more years. In the early years of injecting, women also reported higher rates of receptive sharing of needles and syringe and ancillary equipment when compared to men. Last injecting heroin, methadone or buprenorphine was significantly associated with HCV antibody prevalence amongst both males and females injecting for less than 5 years. Conclusion: Findings indicate that women are at greater risk than men of HCV infection during the early years of injection through higher rates of receptive sharing of needles and syringes and/or ancillary equipment. Our results suggest that women who are new to injecting, and Indigenous women in particular, should be identified as priority populations when developing and implementing harm reduction strategies that target people who inject illicit drugs.

Jones HE; O'Grady KE; Johnson RE; Velez M; Jansson LM. Infant neurobehavior following prenatal exposure to methadone or buprenorphine: Results from the Neonatal Intensive Care Unit Network Neurobehavioral Scale. Substance Use & Misuse 45(13): 2244-2257, 2010. (23 refs.)

This study examined the neurobehavioral functioning of neonates prenatally exposed to methadone (n = 11) or buprenorphine (n = 10), who underwent the Neonatal Intensive Care Unit Network Neurobehavioral Scale (NNNS) examinations on days 3, 5, 7, 10, and 14 post-delivery. Linear mixed model analyses revealed that NNNS scores of arousal and excitability showed significant differences between medications over time. Compared to neonates who did not require medication to treat neonatal abstinence syndrome (NAS), neonates receiving pharmacotherapy for NAS showed differences over time in quality of movement, excitability, and lethargy. Results suggest the NNNS may detect subtle differences over time between both neonates prenatally exposed to methadone or buprenorphine and neonates pharmacologically treated or untreated for NAS.

Kluger N; Girard C; Guillot B; Bessis D. Penile and scrotal skin necrosis after injection of crushed buprenorphine tablets. (editorial). Presse Medicale 39(5): 609-611, 2010. (10 refs.)

Kuehn BM. Buprenorphine during pregnancy. (editorial). Journal of the American Medical Association 305(4): problem ?348-348, 2011. (0 refs.)

Lintzeris N; Nielsen S. Benzodiazepines, methadone and buprenorphine: Interactions and clinical management. (review). American Journal on Addictions 19(1): 59-72, 2010. (122 refs.)

Benzodiazepines (BZDs) are widely used by heroin users not in treatment, and by patients in methadone and buprenorphine (BPN) treatment. This review examines the epidemiology of BZD use by opioid users, and the range of harms that are associated with BZD use in this group, including the association of BZD use with opioid-related mortality. Preclinical and clinical data regarding pharmacokinetic and pharmacodynamic interactions between methadone, buprenorphine, and BZDs are reviewed. An overview of treatment approaches for managing BZD use in this population is presented, including strategies for minimizing abuse and addressing BZD dependence.

Lofwall MR; Walsh SL. Clinical challenges in managing buprenorphine diversion. (editorial). Journal of Addiction Medicine 4(4): 243-243, 2010. (3 refs.)

Lorenzetti V; Lubman DI; Velakoulis D; Yucel M. Pituitary gland volume among heroin users stabilised on substitution pharmacotherapy. Drug and Alcohol Dependence 110(1-2): 164-166, 2010. (10 refs.)

While long-term heroin addiction is associated with hypothalamus-pituitary-adrenal (HPA) axis dysregulation, few studies have used in vivo brain imaging to examine the impact on pituitary gland volume (PGV) or its relationship with substitution pharmacotherapy. We examined 28 heroin users stable on methadone or buprenorphine and 28 healthy controls. Heroin users exhibited larger PGVs than healthy controls, and this was particularly evident among the buprenorphine-treated group. These findings indicate that substitution pharmacotherapy may have differential effects on normalising HPA axis activity.

Luty J; O'Gara C; Sessay M; Sarkhel A. A survey of community drug team prescribing policies and client views. Journal of Substance Use 15(1): 51-59, 2010. (30 refs.)

Aims and methods: A postal and telephone survey of 140 community drug teams in England and Wales was performed to survey existing prescribing policies for substitute prescriptions, including prevalence of supervised methadone consumption, use of methadone higher doses, injectables and prescribed benzodiazepines. Questionnaires were directed to the prescribing doctor. A second survey involved questionnaires distributed to clients at three community drugs teams in Essex. Participants were asked to comment on various aspects of prescribing policies. Results: Results were obtained from 120 community drug teams (86%) and 104 clients who had received substitute prescribing. Around 22% of teams reported that methadone was supervised in a minority of new patients. Low doses (under 60 mg methadone per day) were rarely used (fewer than 10 patients) in 45% of services. Buprenorphine was prescribed in 97% of services. Fewer than half of community drug teams prescribed benzodiazepines (other than alcohol detoxification) or injectable drugs. A total of 104 responses were received from service users in Essex. The majority were opposed to supervised consumptions, although they were in broad agreement with other policies. Conclusion: Regulations concerning supervised consumption of methadone are ignored in at least one-fifth of community drug teams. The opposition of service users to supervised consumption may lead to the continued popularity of methadone to take away in England and Wales. Service users in Essex were generally in agreement with other aspects of prescribing policy including the reluctance to use higher doses of methadone.

Maxwell JC; McCance-Katz EF. Indicators of buprenorphine and methadone use and abuse: What do we know? American Journal on Addictions 19(1): 73-88, 2010. (56 refs.)

Abuse of prescription opioids is a growing problem. The number of methadone pain pills distributed now exceeds liquid methadone used in opioid treatment, and the increases in buprenorphine indicators provide evidence of the need to monitor and intervene to decrease the abuse of this drug. The need for additional and improved data to track trends is discussed, along with findings as to the characteristics of the users and combinations of drugs. Data on toxicities related to methadone or buprenorphine, particularly in combination with other prescribed drugs, are presented and clinical implications and considerations are offered. These findings underscore the need for physicians to be aware of potential toxicities and to educate their patients regarding these issues.

McCance-Katz EF; Jatlow P; Rainey PM. Effect of cocaine use on methadone pharmacokinetics in humans. American Journal on Addictions 19(1): 47-52, 2010. (33 refs.)

Chronic cocaine use has been shown to significantly decrease buprenorphine concentrations in the blood with potential for adverse events and poor treatment response. In this study, we investigated whether a similar drug interaction occurred between cocaine and methadone. In a retrospective analysis, methadone pharmacokinetics were compared for those who were either regular cocaine users (N = 16) or with intermittent or no cocaine use (N = 23). Participants who used cocaine regularly showed a significant decrease in C-min (p = .04) and a trend for decreased AUC (p = .09) and more rapid methadone clearance (p = .08). Regular cocaine use may adversely impact treatment outcomes for opioid dependence in those receiving methadone maintenance by decreasing methadone exposure.

McCance-Katz EF; Mandell TW. Drug interactions of clinical importance with methadone and buprenorphine. American Journal on Addictions 19(1): 2-3, 2010. (2 refs.)

McCance-Katz EF; Rainey PM; Moody DE. Effect of cocaine use on buprenorphine pharmacokinetics in humans. American Journal on Addictions 19(1): 38-46, 2010. (46 refs.)

The effect of chronic cocaine use on buprenorphine pharmacokinetics was investigated to identify drug interactions and potential toxicities. In a retrospective analysis, pharmacokinetics were compared for 16 studies completed on subjects who were regular cocaine users and 74 studies on subjects who used cocaine only occasionally or not at all. All participants were stably maintained on buprenorphine/naloxone 16/4 mg daily. Participants who used cocaine regularly had lower buprenorphine exposure (AUC 34% lower; C-max 27% lower and C-24 37% lower; p < .001 for all comparisons). Regular cocaine users were younger (p = .0007), and used more heroin (p = .004) and cocaine (p < .0001). Regular cocaine use may result in lower buprenorphine plasma concentrations with potential for adverse clinical outcomes.

McCance-Katz EF; Sullivan LE; Nallani S. Drug interactions of clinical importance among the opioids, methadone and buprenorphine, and other frequently prescribed medications: A review. American Journal on Addictions 19(1): 4-16, 2010. (92 refs.)

Drug interactions are a leading cause of morbidity and mortality. Methadone and buprenorphine are frequently prescribed for the treatment of opioid addiction. Patients needing treatment with these medications often have co-occurring medical and mental illnesses that require medication treatment. The abuse of illicit substances is also common in opioid-addicted individuals. These clinical realities place patients being treated with methadone and buprenorphine at risk for potentially toxic drug interactions. A substantial literature has accumulated on drug interactions between either methadone or buprenorphine with other medications when ingested concomitantly by humans. This review summarizes current literature in this area.

Meader N. A comparison of methadone, buprenorphine and alpha(2) adrenergic agonists for opioid detoxification: A mixed treatment comparison meta-analysis. Drug and Alcohol Dependence 108(1-2): 110-114, 2010. (38 refs.)

Objectives: The aim of this systematic review was to compare the efficacy of methadone, buprenorphine, clonidine and lofexidine for opioid detoxification. Mixed treatment comparison meta-analyses were used to synthesise the data as it is designed for data-sets where limitations in standard pairwise meta-analyses make comparisons difficult to interpret. Data sources: A systematic search was conducted using the following databases: CENTRAL, CINAHL, Embase, HMIC, Medline and PsycINFO. Review methods: RCTs that included opioid dependent participants over a mean age of 16 receiving opioid detoxification using buprenorphine, methadone, clonidine or lofexidine were included in the systematic review. Included studies were quality assessed and the completion of treatment data was extracted by the author and a research assistant independently. Mixed treatment comparison methods were used to synthesise the data. Results: There were 23 RCTs included in the systematic review (and 20 included in the meta-analysis) comprising a total of 2112 participants. Buprenorphine and methadone were ranked as the most effective methods of opioid detoxification followed by lofexidine and clonidine respectively. Conclusion: Buprenorpine and methadone appear to be the most effective detoxification treatments. While the analysis suggests buprenorphine is the most effective method of detoxification there is some uncertainty on whether it is more effective than methadone and requires further research to confirm this result.

Mei W; Zhang JX; Xiao Z. Acute effects of sublingual buprenorphine on brain responses to heroin-related cues in early-abstinent heroin addicts: An uncontrolled trial. Neuroscience 170(3): 808-815, 2010. (41 refs.)

Replacement therapy with buprenorphine is clinically effective in reducing withdrawal and craving for heroin during detoxification but not in decreasing the probability of relapse after detoxification. This study examined the acute effects of buprenorphine on brain responses to heroin-related cues to reveal the neurobiological and therapeutic mechanisms of addiction and relapse. Fifteen heroin addicts at a very early period of abstinence, were studied in two separate periods 10-15 min apart: an early period (5-45 min) and a later period (60-105 min) after sublingual buprenorphine, roughly covering the onset and peak of buprenorphine plasma level. During both periods, fMRI scanning with heroin-related visual stimuli were performed followed by questionnaires. Under effect of buprenorphine, brain responses to heroin-related cues showed decrease in amygdala, hippocampus, ventral tegmental area (VTA) and thalamus but no changes in ventral striatum and orbital-prefrontal-parietal cortices. As an uncontrolled trial, these preliminary results suggest that buprenorphine has specific brain targets in reducing withdrawal and craving during early abstinence, and that ventral striatum and orbital prefrontal parietal cortices may be the key targets in developing therapy for drug addiction and relapse.

Nanjayya SB; Murthy P; Chand PK; Kandaswamy A; Nikketha B; Benegal V et al. A case of poppy tea dependence in an octogenarian lady. Drug and Alcohol Review 29(2): 216-218, 2010. (6 refs.)

While poppy seed and poppy tea dependence has been described, it is unusual to see such patients actively seek treatment in India. We report the case of an 82-year-old client with dependent use of poppy for 55 years. She was brought for treatment as access to poppy became difficult following legal restrictions. She was successfully maintained on buprenorphine maintainence.

Oechsler S; Skopp G. Buprenorphine and major metabolites in blood specimens collected for drug analysis in law enforcement purposes. Forensic Science International 195(1-3): 73-77, 2010. (22 refs.)

A liquid chromatographic/electrospray ionization tandem mass spectrometric method for the quantification of buprenorphine (BUP), norbuprenorphine (NBUP), buprenorphine-3-beta-D-glucuronide (BUPG) and norbuprenorphine-3-beta-D-glucuronide (NBUPG) in serum samples was developed and validated. Pre-treatment of BUP and NBUP was by liquid-liquid extraction, while glucuronides were favourably isolated by solid phase extraction. Separation in 2 separate runs (2 x 5 min) was achieved using isocratic elution. The method was applied to 20 authentic serum specimens collected for law enforcement purposes where BUP intake had been indicated. The parent drug was not detectable in half of the specimens at a lower limit of detection of 0.2 ng/mL, whereas NBUP could be determined from any sample but one. NBUPG is the majormetabolite present, which could be identified along with BUPG in all samples under investigation. In authentic specimens it could be advisable to monitor BUP metabolites along with the parent drug.

Parran TV; Adelman CA; Merkin B; Pagano ME; Defranco R; Ionescu RA et al. Long-term outcomes of office-based buprenorphine/naloxone maintenance therapy. Drug and Alcohol Dependence 106(1): 56-60, 2010. (41 refs.)

Background: Buprenorphine/naloxone was approved by the FDA for office-based opioid maintenance therapy (OMT), with little long-term follow-up data from actual office-based practice. 18-Month outcome data on the office-based use of buprenorphine/naloxone (bup/nx) and the impact of socioeconomic status and other patient characteristics on the duration and clinical effects of bup/nx are reported. Methods: This retrospective chart review and cross-sectional telephone inter-view provide treatment retention of opioid-dependent patients receiving bup/nx-OMT in an office-based setting. 176 opioid-dependent patients from two different socioeconomic groups (high and low SES) were begun on bup/nx, started intensive outpatient treatment, and followed-up after a minimum of 18 months (18-42 months) by telephone interview to assess treatment outcome. Results: 110 subjects (67%) completed the interview, 77% remained on bup/nx with no difference in retention between high and low SES groups. Those on bup/nx at follow-up were more likely to report abstinence, to be affiliated with 12-step recovery, to be employed and to have improved functional status. Conclusions: Bup/nx-OMT is a viable treatment option and when coupled with a required abstinence oriented addiction counseling program is effective in promoting abstinence, self-help group attendance, occupational stability, and improved psychosocial outcomes in both low SES and high SES patient populations over an 18-42-month period.

Pauly V; Frauger E; Pradel V; Rouby F; Berbis J; Natali F et al. Which indicators can public health authorities use to monitor prescription drug abuse and evaluate the impact of regulatory measures? Controlling high dosage buprenorphine abuse. Drug and Alcohol Dependence 113(1): 29-36, 2011. (46 refs.)

Background: Two methods have been recently developed from a drug reimbursement database to provide useful indicators for public health authorities concerning the abuse potential of psychotropic drugs. The doctor-shopping indicator (DSI) measures the proportion of the drug obtained by doctor shopping among the overall quantity of the drug reimbursed and the clustering method reveals subgroups of deviant patients. Objective: The objective of the study was to analyze and compare indicators resulting from these two methods, applied to High Dosage Buprenorphine (HDB) (a product well-known to be diverted in France), in order to determine which public health authorities needs they answer. Data analysis: The patients with reimbursed HDB were grouped using the clustering method in terms of drug dispensations characteristics over a nine month period. The characteristics of the resulting subgroups, including their DSI, were then compared. Results: 4787 Patients (73.4%) had no measurable doctor-shopping behaviour. But the comparison of the two methods demonstrated that the more a patient's profile was characterized by deviant behavior, the higher was the DSI: from 0.4% in a subgroup with a median profile to 72% in a subgroup with a deviant profile. Conclusion: These two methods are useful surveillance tools for public health authorities: the clustering method may help devise pertinent intervention strategies to reduce prescription drug abuse while the DSI method provides quantitative information demonstrating whether these strategies are useful. We discuss the advantages and disadvantages of using these two methods as useful indicators for public health authorities.

Pinto H; Maskrey V; Swift L; Rumball D; Wagle A; Holland R. The SUMMIT Trial: A field comparison of buprenorphine versus methadone maintenance treatment. Journal of Substance Abuse Treatment 39(4): 340-352, 2010. (31 refs.)

This prospective patient-preference study examined the effectiveness in practice of methadone versus buprenorphine maintenance treatment and the beliefs of subjects regarding these drugs. A total of 361 opiate-dependent individuals (89% of those eligible, presenting for treatment over 2 years at a drug service in England) received rapid titration then flexible dosing with methadone or buprenorphine; 227 patients chose methadone (63%) and 134 buprenorphine (37%). Participants choosing methadone had more severe substance abuse and psychiatric and physical problems but were more likely to remain in treatment. Survival analysis indicated those prescribed methadone were over twice as likely to be retained (hazard ratio for retention was 2 08 and 95% confidence interval [CI] = 1 49-2 94 for methadone vs buprenorphine). However, those retained on buprenorphine were more likely to suppress illicit opiate use (odds ratio = 2 136, 95% CI = 1 509-3 027,p < 001) and achieve detoxification. Buprenorphine may also recruit more individuals to treatment because 28% of those choosing buprenorphine (10% of the total sample) stated they would not have accessed treatment with methadone.

Ponizovsky AM; Margolis A; Heled L; Rosca P; Radomislensky I; Grinshpoon A. Improved quality of life, clinical, and psychosocial outcomes among heroin-dependent patients on ambulatory buprenorphine maintenance. Substance Use & Misuse 45(1/2): 288-313, 2010. (78 refs.)

Aim: A prospective longitudinal design was employed to examine the effects of buprenorphine maintenance on quality of life (QOL), clinical, and psychosocial characteristics of heroin-dependent patients. Method: Between 2003 and 2005 data were collected on 259 patients attending the outpatient centers for treatment of drug addictions across Israel, of which 157 were reevaluated 16 weeks later and 105 reevaluated 32 weeks later using the Clinical Global Impression, Distress Scale for Adverse Symptoms, Quality of Life Enjoyment and Satisfaction Questionnaire, General Health Questionnaire, General Self-Efficacy Scale, and the Multidimensional Scale of Perceived Social Support. Univariate and multivariate analyses were conducted to examine the association between the parameters and the cross-sectional and longitudinal predictions of the QOL outcomes. Results: The groups did not differ in baseline values and their post-treatment ratings revealed significant improvement on virtually all the scales. Perceived self-efficacy and social support from friends and significant others at baseline as well as their changes over time were the best predictors of the QOL in the short and long terms. The study's limitations are noted. Conclusions: The beneficial effects on the QOL were associated with improvement in the psychosocial parameters and a reduction in buprenorphine-related side effects and psychological distress. This study could stimulate research to compare the QOL related to buprenorphine and methadone treatment and serve as a basis on which a controlled study should be performed.

Quaglio G; Pattaro C; Gerra G; Mezzelani P; Montanari L; Des Jarlais DC et al. Buprenorphine in maintenance treatment: Experience among Italian physicians in drug addiction centers. (editorial). American Journal on Addictions 19(3): 222-230, 2010. (27 refs.)

The aim of this study was to assess the attitudes of Italian physicians regarding buprenorphine and its clinical use approximately 6 years after the medication was introduced into clinical practice. The sample consisted of 305 randomly selected physicians, working in public centers of drug addiction. In Italy buprenorphine seems a valid tool in the field of drug addiction treatment, although it is far from replacing methadone even though it seems to guarantee better compliance. Interviewees follow clinical experience more than international guidelines, with pharmaceutical company representatives as the most cited source for information about the medication. The data also suggests a need for the development of formal guidelines for treatment with buprenorphine in Italy.

Salsitz EA; Holden CC; Tross S; Nugent A. Transitioning stable methadone maintenance patients to buprenorphine maintenance. Journal of Addiction Medicine 4(2): 88-92, 2010. (15 refs.)

Objectives: Little data exists on psychosocially stable patients maintained long term on methadone maintenance treatment who attempt to transition their maintenance treatment to buprenorphine. The aims of this study were (1) to determine whether there is a correlation between baseline methadone maintenance dose and final buprenorphine maintenance dose, (2) to investigate subjective and objective outcomes over time in psychosocially stable opioid-dependent patients who transitioned their long-term maintenance treatment from methadone to buprenorphine. Methods: In this retrospective study, 104 such patients on dosages of methadone 5 to 80 mg/d were offered the opportunity to convert their maintenance treatment to buprenorphine, of which 25 accepted. Results: All patients (n = 25, 100%) who readily attempted transition to buprenorphine succeeded. A low-moderate association was found between patients' pretransfer methadone dose and posttransfer buprenorphine dose (Spearman correlation coefficient rho = 0.46, P = 0.02). At a mean 30.3 months duration(SD 16.5), 22 patients (88%) remained on buprenorphine maintenance, 1 patient (4%) tapered off buprenorphine under clinician supervision, 1 patient (4%) died of hepatitis C, and 1 patient (4%) relapsed to cocaine and was lost to follow-up. Conclusions: The results demonstrate a low to moderate association between methadone and buprenorphine maintenance doses, and that buprenorphine is a viable maintenance treatment for opioid dependence for psychosocially stable patients on long-term methadone maintenance dosages up to 80 mg/d.

Schmid M; Kuessel L; Klein K; Metz V; Fischer G; Krampl-Bettelheim E. First-trimester fetal heart rate in mothers with opioid addiction. Addiction 105(7): 1265-1268, 2010. (27 refs.)

Aim: To investigate the difference in fetal heart rate of opioid-dependent mothers compared to non-dependent mothers in the first trimester of pregnancy. Design: The data of 74 consecutive singleton pregnancies of mothers enrolled in a maintenance programme for opioid-dependent women was matched to 74 non-exposed singleton pregnancies by maternal age, crown-rump length, smoking status, ethnic background and mode of conception. Measurement: Fetal heart rate measured as part of first-trimester screening by Doppler ultrasound between 11+0 and 13+6 gestational weeks was compared retrospectively. Findings: The mean fetal heart rate in opioid-dependent mothers was 156.0 beats per minute (standard deviation 7.3) compared to 159.6 (6.5) in controls. The difference in fetal heart rate was significant (P = 0.02). There was a significant difference in mean maternal body mass index (P = 0.01) but not in mean nuchal translucency (P = 0.3), gestational age (0.5), fetal gender (P = 0.3) and parity (P = 0.3) between both groups. Fifty-five per cent (41 of 74) of cases were taking methadone, 30% (22 of 74) buprenorphine and 15% (11 of 74) were taking slow-release morphines throughout the pregnancy. Conclusions: In fetuses of opioid-dependent mothers a decreased fetal heart rate can already be observed between 11+0 and 13+6 gestational weeks. The effect of opioid intake needs to be taken into consideration when interpreting fetal heart rate in opioid-dependent mothers at first-trimester screening.

Skopp G; Kniest A; Haisser J; Mann K; Hermann D. Buprenorphine and norbuprenorphine findings in hair during constant maintenance dosage. International Journal of Legal Medicine 125(2): 277-281, 2011. (19 refs.)

It is still a matter of debate whether a positive correlation between the dose and the amount of drug in the hair exists. Drugs such as buprenorphine (BUP) used under controlled conditions present an opportunity to prove a possible relationship. Due to discrepant findings of BUP/norbuprenorphine (NBUP) ratios in hair, in vitro degradation of both analytes in diluted acid was also investigated. The levels of BUP and NBUP in proximal hair sections from 18 subjects participating in a maintenance program were determined by liquid chromatography/tandem mass spectrometry following incubation with methanol and subsequent liquid/liquid extraction. BUP and NBUP were incubated in diluted hydrochloric acid at 60A degrees C for up to 24 h. The alleged rearrangement products were simultaneously monitored. All hair samples tested positive for BUP (lower limit of detection-0.238 ng/mg hair) and NBUP (0.043-0.961 ng/mg hair). The concentration of NBUP in hair was consistently higher than that of BUP except for a single specimen. Degradation of BUP and NBUP was dependent on time; hydrolysis of NBUP occurred faster than that of BUP. The concentration of BUP and NBUP will be underestimated if analytes are recovered by acidic procedures. NBUP should be monitored in hair samples besides BUP for the sum of both BUP and NBUP may provide an estimate of BUP exposure following long-term administration of the drug.

Sohler NL; Li X; Kunins HV; Sacajiu G; Giovanniello A; Whitley S et al. Home- versus office-based buprenorphine inductions for opioid-dependent patients. Journal of Substance Abuse Treatment 38(2): 153-159, 2010. (22 refs.)

Recent legislation permits the treatment of opioid-dependent patients with buprenorphine in the primary care setting, opening doors for the development of new treatment models for opioid dependence. We modified national buprenorphine treatment guidelines to emphasize patient self-management by giving patients the opportunity to choose to have buprenorphine inductions at home or the physician's office. We examined whether patients who had home-based inductions achieved greater 30-day retention than patients who had traditional office-based inductions in a study of 115 opioid-dependent patients treated in an inner-city health center. Retention was similar in both groups: 50 (78.1%) in office-based group versus 40 (78.4%) in home-based group, p = .97. Several patient characteristics were associated with choosing office- versus home-based inductions, which likely influenced these results. We conclude that opioid dependence can be successfully managed in the primary care setting. Approaches that encourage patient involvement in treatment for opioid dependence can be beneficial.

Solomon SS; Desai M; Srikrishnan AK; Thamburaj E; Vasudevan CK; Kumar MS et al. The profile of injection drug users in Chennai, India: Identification of risk behaviours and implications for interventions. Substance Use & Misuse 45(3): 354-367, 2010. (21 refs.)

We characterize the demographics, injection practices and risk behaviours of 1,158 injection drug users (IDUs) in Chennai, the capital of Tamil Nadu in southern India, who were recruited during 2005-2006 by community outreach. The median age was 35 years; the majority of IDUs were male, of Tamil ethnicity and married, and earning less than US$75 per month. Most (76%) had injected in the prior month. The median age at first injection was 25 years; the most common drug injected was heroin (80%) followed by buprenorphine. High risk behaviours were common and included needle-sharing, unsafe disposal, and inappropriate cleaning of needles as well as limited condom use. IDUs in India need to be educated on harm reduction and safe-injection practices; Pharmacies could serve as potential venues for HIV prevention interventions among IDUs in India, as most IDUs obtain their needles from pharmacies without prescription.

Strain EC; Harrison JA; Bigelow GE. Induction of opioid-dependent individuals onto buprenorphine and buprenorphine/naloxone soluble-films. Clinical Pharmacology & Therapeutics 89(3): 443-449, 2011. (22 refs.)

A sublingual soluble-film formulation of buprenorphine/naloxone (B/N) has been approved by the US Food and Drug Administration for the treatment of opioid dependency. This preparation provides unit-dose, child-resistant packaging amenable to tracking and accountability, offers more rapid dissolution, and has a potentially preferred taste vs. tablets. This study compared the ability of buprenorphine (B) and B/N films to suppress spontaneous withdrawal in opioid-dependent volunteers. Participants were maintained on morphine and underwent challenge sessions to confirm sensitivity to naloxone-induced opioid withdrawal. Subjects were randomized to receive either B (16 mg, n = 18) or B/N (16/4 mg, n = 16) soluble films for 5 days. The primary outcome measure was the Clinical Opiate Withdrawal Scale (COWS) score. Thirty-four subjects completed induction onto soluble films. There was a significant decrease in COWS scores but no significant differences between the groups. The results support the use of B and B/N soluble films as safe and effective delivery methods for opioid induction.

Wallack SS; Thomas CP; Martin TC; Chilingerian J; Reif S. Substance abuse treatment organizations as mediators of social policy: Slowing the adoption of a congressionally approved medication. Journal of Behavioral Health Services & Research 37(1): 64-78, 2010. (55 refs.)

Most substance abuse treatment occurs in outpatient treatment centers, necessitating an understanding of what motivates organizations to adopt new treatment modalities. Tichy's framework of organizations as being comprised of three intertwined internal systems (technical, cultural, and political) was used to explain treatment organizations' slow adoption of buprenorphine, a new medication for opiate dependence. Primary data were collected from substance abuse treatment organizations in four of the ten metropolitan areas with the largest number of heroin users. Only about one fifth offered buprenorphine. All three internal systems were important determinants of buprenorphine adoption in our multivariate model. However, the cultural system, measured by attitude toward medications, was a necessary condition for adoption. Health policies designed to encourage adoption of evidence-based performance measures typically focus on the technical system of organizations. These findings suggest that such policies would be more effective if they incorporate an understanding of all three internal systems.

Wang EA; Moore BA; Sullivan LE; Fiellin DA. Effect of incarceration history on outcomes of primary care office-based buprenorphine/naloxone. Journal of General Internal Medicine 25(7): 670-674, 2010. (42 refs.)

Behaviors associated with opioid dependence often involve criminal activity, which can lead to incarceration. The impact of a history of incarceration on outcomes in primary care office-based buprenorphine/naloxone is not known. The purpose of this study is to determine whether having a history of incarceration affects response to primary care office-based buprenorphine/naloxone treatment. In this post hoc secondary analysis of a randomized clinical trial, we compared demographic, clinical characteristics, and treatment outcomes among 166 participants receiving primary care office-based buprenorphine/naloxone treatment stratifying on history of incarceration. Participants with a history of incarceration have similar treatment outcomes with primary care office-based buprenorphine/naloxone than those without a history of incarceration (consecutive weeks of opioid-negative urine samples, 6.2 vs. 5.9, p = 0.43; treatment retention, 38% vs. 46%, p = 0.28). Prior history of incarceration does not appear to impact primary care office-based treatment of opioid dependence with buprenorphine/naloxone. Community health care providers can be reassured that initiating buprenorphine/naloxone in opioid dependent individuals with a history of incarceration will have similar outcomes as those without this history.

Wesson DR; Smith DE. Buprenorphine in the treatment of opiate dependence. (review). Journal of Psychoactive Drugs 42(2): 161-175, 2010. (113 refs.)

Compelling clinical evidence establishes that buprenorphine is similar to methadone in efficacy for opiate detoxification and maintenance but safer than methadone in an overdose situation. The Drug Abuse Treatment Act of 2000 (DATA 2000) enabled US physicians with additional training to prescribe buprenorphine to a limited number of opiate-dependent patients. The sublingual tablets Subutex (R) (buprenorphine alone) and Suboxone (R) (a combination of buprenorphine and naloxone) meet the specifications of DATA 2000. Suboxone is intended to discourage intravenously administration and has less abuse potential than buprenorphine alone. Suboxone is generally recommended for maintenance treatment except for women who are pregnant. Subutex is recommended in treatment of pregnant women. A buprenorphine opiate withdrawal syndrome can occur in newborns. Although intravenous buprenorphine abuse is a significant public health problem in some countries, buprenorphine alone or in combination with naloxone has less potential for abuse than heroin and some prescription opiates, such as oxycodone. Pharmacotherapy from physicians' offices makes buprenorphine treatment acceptable to some opiate-dependent patients who would not accept treatment in traditional opiate-maintenance clinics. For reasons not adequately understood, some patients find discontinuation of buprenorphine following long-term use difficult. This article reviews the pharmacology of buprenorphine, summarizes evidence supporting the safety and efficacy of buprenorphine and provides clinical guidelines for treatment.