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Data demonstrate buprenorphine's effectiveness.

We read with great interest Steven R. Scanlan, MD's article "Suboxone: concerns behind the miracle" (November/December 2010 issue), and we are writing to elaborate on several points and to review detoxification and maintenance treatment evidence to expand upon his anecdotal experience.

Opioid dependence remains largely untreated nationally; the expansion of office-based opioid treatment (OBOT) with buprenorphine is needed to address the treatment gap and to minimize associated morbidity and mortality when the disease is left untreated. In the office model, clinicians have opportunities to present patients with various treatment options that include use of non-pharmacotherapy, pharmacotherapy using buprenorphine and buprenorphine/naloxone (hereafter collectively termed "buprenorphine"), and referral to specialty professionals and services, including methadone maintenance therapy.

Mutual treatment planning often involves a decision whether to initiate buprenorphine maintenance treatment or to use the medication as a means of detoxification from the misused opioid. In his article, Dr. Scanlan advocates the use of detoxification primarily over a three-to-four week period to avoid numerous complications of maintenance in which "one addiction may be traded for another."

We are concerned that the view equating buprenorphine maintenance with buprenorphine addiction reflects a common misconception about diagnostic criteria, and is unsupported by scientific evidence. Physical dependence on a substance is neither necessary nor sufficient for a DSM-IV substance dependence diagnosis, which is used interchangeably with addiction. Although buprenorphine-maintained patients on a stable long-term dose have physical dependence, including withdrawal with abrupt cessation, a lack of compulsive and uncontrolled problematic use precludes a buprenorphine-specific addiction diagnosis in these individuals.

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Voluminous data

An extensive and growing body of research supports that positive long-term patient- and system-level outcomes can be achieved in primary care and other outpatient settings with buprenorphine maintenance treatment--even for traditionally vulnerable patient populations such as those who have HIV or who are homeless. (1), (2), (3), (4)

OBOT with buprenorphine improves treatment engagement (roughly 50 to 60 percent retention at six months) and reduces cravings, illicit opioid use and mortality. (4), (5), (6), (7), (8), (9) Furthermore, long-term methadone maintenance therapy has a long history of evidence for successful patient outcomes; long-term OBOT with buprenorphine is an analogous treatment paradigm.

Although detoxification with buprenorphine may be more effective than non-opioid based detoxification approaches, (10) the clinical effectiveness of buprenorphine detoxification appears less than that of buprenorphine maintenance. In a recent National Institutes of Health (NIH)-sponsored multi-site trial comparing buprenorphine-tapering schedules that overlap with Dr. Scanlan's approach, patients were tapered over seven or 28 days after a four-week period of stabilization. (11) Approximately 85 percent in each group were actively using illicit opioids after the taper completed, in follow-up at one and three months. In contrast, an evaluation of long-term, primary care buprenorphine maintenance found a 9 percent opioid-positive urine toxicology during years two to five of follow-up (101 out of 1,106 samples). (4) Patients received monthly brief physician counseling to promote abstinence, self-help involvement and functional improvement.

Prescriptive detoxification (four-week taper) in OBOT with buprenorphine will minimize provider-patient individualization of treatment and be contrary to the intention of federal legislation allowing OBOT.

Addressing bias

Despite the demonstrated benefits of buprenorphine maintenance treatment, many in the substance abuse treatment community may continue to view agonist maintenance as not being in "recovery." Although recovery is variably defined, (12) maintenance treatment when coupled with standard-of-care psychosocial treatment is capable of producing long-term sustained remission to alleviate the lifelong struggle for many individuals.

We agree that buprenorphine alone is not a "miracle cure" but rather a means of providing enough stabilization so that the patient may participate in the rehabilitative process. Non-pharmacotherapy and pharmacotherapy should be offered to all patients with opioid dependence.

We too are concerned about so-called "script docs" collecting monthly out-of-pocket cash fees for 5- to 10-minute refill visits without patient engagement in ancillary care. Such practice is largely outside the norm, with most prescribers either offering psychosocial treatment on-site or utilizing outside referral, (13) consistent with national guidelines. (14) We are equally concerned about a "revolving door" of detoxification in which patients cycle in and out of acute care for repeated detoxifications. In addition to likely limited cost-effectiveness, the approach puts patients at risk for overdose during relapse due to the decreased physical dependence occurring at the end of a taper.

Ultimately, given the heterogeneity of the disease of opioid dependence, patients will be best served by having an array of service options that are not mutually exclusive. We hope that through continued questioning of clinical dogma and paradigms, such as that raised by Dr. Scanlan, as well as through further scientific study, patients will gain greater access to effective treatment--and the tremendous individual and societal consequences of untreated opioid dependence will be mitigated.

References

(1.) Alford DP, LaBelle CT, Richardson JM, et al. Treating homeless opioid dependent patients with buprenorphine in an office-based setting. J Gen Intern Med 2007 Feb;22:171-6.

(2.) Parran TV, Adelman CA, Merkin B, et al. Long-term outcomes of office-based buprenorphine/naloxone maintenance therapy. Drug Alcohol Depend 2010 Jan 1;106:56-60.

(3.) Sullivan LE, Moore BA, Chawarski MC, et al. Buprenorphine/naloxone treatment in primary care is associated with decreased human immunodeficiency virus risk behaviors. J Subst Abuse Treat 2008 Jul;35:87-92.

(4.) Fiellin DA, Moore BA, Sullivan LE, et al. Long-term treatment with buprenorphine/naloxone in primary care: results at 2-5 years. Am J Addict 2008 Mar-Apr;17:116-20.

(5.) Fudala PJ, Bridge TP, Herbert S, et al. Office-based treatment of opiate addiction with a sublingual-tablet formulation of buprenorphine and naloxone. N Engl J Med 2003;349:949-58.

(6.) Fiellin DA, Pantalon MV, Chawarski MC, et al. Counseling plus buprenorphine-naloxone maintenance therapy for opioid dependence. N Engl J Med 2006 Jul 27;355:365-74.

(7.) Mattick RP, Kimber J, Breen C, et al. Buprenorphine maintenance versus placebo or methadone maintenance for opioid dependence. Cochrane Database Syst Rev 2008;CD002207.

(8.) Gunderson EW, Fiellin DA. Office-based maintenance treatment of opioid dependence: How docs it compare with traditional approaches? CNS Drugs 2008;22:99-111.

(9.) Gibson A, Degenhardt L, Mattick RP, et al. Exposure to opioid maintenance treatment reduces long-term mortality. Addiction 2008 Mar; 103:462-8.

(10.) Veilleux JC, Colvin PJ, Anderson J, et al. A review of opioid dependence treatment: pharmacological and psychosocial interventions to treat opioid addiction. Clin Psychol Rev 2010 Mar;30:155-66.

(11.) Ling W, Hillhouse M, Domier C, et al. Buprenorphine tapering schedule and illicit opioid use. Addiction 2009 Feb; 104:256-65.

(12.) McLellan T. What is recovery? Revisiting the Betty Ford Institute Consensus Panel Definition: The Betty Ford Consensus Panel and Consultants. J Subst Abuse Treat 2010 Mar;38:200-1.

(13.) Walley AY, Alperen JK, Cheng DM, et al. Office-based management of opioid dependence with buprenorphine: clinical practices and barriers. J Gen Intern Med 2008 Scp;23:1393-8.

(14.) Center for Substance Abuse Treatment. Clinical guidelines for the use of buprenorphine in the treatment of opioid addiction. Treatment Improvement Protocol (TIP) Series 40. DHHS Publication No. (SMA) 04-3939. Rockville, Md.: Substance Abuse and Mental Health Services Administration; 2004.

Take the Continuing Education Credits Quiz associated with this article on page 37.

Erik W. Gunderson, MD, is an Assistant Professor of Psychiatry and Neurobehavioral Sciences at the University of Virginia School of Medicine. His e-mail address is EWG2N@hscmail.mcc.virginia.edu. Adam J. Gordon, MD, MPH, FACP, FASAM, is an Associate Professor of Medicine at the University of Pittsburgh School of Medicine.
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Title Annotation:Medical Insight
Author:Gunderson, Erik W.; Gordon, Adam J.
Publication:Addiction Professional
Date:Jan 1, 2011
Words:1236
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