Use of microdoses for induction of buprenorphine treatment with overlapping full opioid agonist use: the Bernese method

Robert Hämmig, Antje Kemter, Johannes Strasser, Ulrich von Bardeleben, Barbara Gugger, Marc Walter, Kenneth M Dürsteler, Marc Vogel, Robert Hämmig, Antje Kemter, Johannes Strasser, Ulrich von Bardeleben, Barbara Gugger, Marc Walter, Kenneth M Dürsteler, Marc Vogel

Abstract

Background: Buprenorphine is a partial µ-opioid receptor agonist used for maintenance treatment of opioid dependence. Because of the partial agonism and high receptor affinity, it may precipitate withdrawal symptoms during induction in persons on full µ-opioid receptor agonists. Therefore, current guidelines and drug labels recommend leaving a sufficient time period since the last full agonist use, waiting for clear and objective withdrawal symptoms, and reducing pre-existing full agonist therapies before administering buprenorphine. However, even with these precautions, for many patients the induction of buprenorphine is a difficult experience, due to withdrawal symptoms. Furthermore, tapering of the full agonist bears the risk of relapse to illicit opioid use.

Cases: We present two cases of successful initiation of buprenorphine treatment with the Bernese method, ie, gradual induction overlapping with full agonist use. The first patient began buprenorphine with overlapping street heroin use after repeatedly experiencing relapse, withdrawal, and trauma reactivation symptoms during conventional induction. The second patient was maintained on high doses of diacetylmorphine (ie, pharmaceutical heroin) and methadone during induction. Both patients tolerated the induction procedure well and reported only mild withdrawal symptoms.

Discussion: Overlapping induction of buprenorphine maintenance treatment with full µ-opioid receptor agonist use is feasible and may be associated with better tolerability and acceptability in some patients compared to the conventional method of induction.

Keywords: heroin; opiate; suboxone; substitution; subutex.

Figures

Figure 1
Figure 1
Daily buprenorphine dose (mg), full agonist dose (in MEQDD), and SOWS scores of case 2. Abbreviations: MEQDD, methadone equivalent daily dose; SOWS, short opioid withdrawal scale.

References

    1. Mattick RP, Breen C, Kimber J, Davoli M. Buprenorphine maintenance versus placebo or methadone maintenance for opioid dependence. Cochrane Database Syst Rev. 2014;2:CD002207.
    1. Anchersen K, Clausen T, Gossop M, Hansteen V, Waal H. Prevalence and clinical relevance of corrected QT interval prolongation during methadone and buprenorphine treatment: a mortality assessment study. Addiction. 2009;104:993–999.
    1. Degenhardt L, Randall D, Hall W, Law M, Butler T, Burns L. Mortality among clients of a state-wide opioid pharmacotherapy program over 20 years: risk factors and lives saved. Drug Alcohol Depend. 2009;105:9–15.
    1. Swiss Society of Addiction Medicine (SSAM) Clinical Recommendations for Substitution-assisted Treatment in Opioid Dependence 2012 [Medizinische Empfehlungen für substitutionsgestützte Behandlungen (SGB) bei Opioidabhängigkeit 2012] Mediscope AG, Zurich: Swiss Society of Addiction Medicine; 2013. [Accessed March 30, 2015]. Available from: .
    1. Jasinski DR, Preston KL. Laboratory studies of buprenorphine in opioid abusers. In: Cowan A, Lewis J, editors. Buprenorphine: Combatting Drug Abuse with a Unique Opioid. New York, NY: Wiley-Liss, Inc; 1995. pp. 189–211.
    1. FDA US Food and Drug Administration . Buprenorphine – Drug Label. Silver Spring, MD: Food and Drug Administration; 2010. [Accessed November 21, 2015]. Available from: .
    1. Center for Substance Abuse Treatment . Clinical Guidelines for the Use of Buprenorphine in the Treatment of Opioid Addiction. Rockville, MD: Substance Abuse and Mental Health Services Administration; 2004. [Accessed November 30, 2015]. Available from: .
    1. Levin FR, Fischman MW, Connerney I, Foltin RW. A protocol to switch high-dose, methadone-maintained subjects to buprenorphine. Am J Addict. 1997;6:105–116.
    1. Mattick RP, Ali R, White JM, O’Brien S, Wolk S, Danz C. Buprenorphine versus methadone maintenance therapy: a randomized double-blind trial with 405 opioid-dependent patients. Addiction. 2003;98:441–452.
    1. Pani PP, Maremmani I, Pirastu R, Tagliamonte A, Gessa GL. Buprenorphine: a controlled clinical trial in the treatment of opioid dependence. Drug Alcohol Depend. 2000;60:39–50.
    1. Petitjean S, Stohler R, Déglon JJ, et al. Double-blind randomized trial of buprenorphine and methadone in opiate dependence. Drug Alcohol Depend. 2001;62:97–104.
    1. Schottenfeld RS, Pakes JR, Oliveto A, Ziedonis D, Kosten TR. Buprenorphine vs methadone maintenance treatment for concurrent opioid dependence and cocaine abuse. Arch Gen Psychiatry. 1997;54:713–720.
    1. Comer SD, Walker EA, Collins ED. Buprenorphine/naloxone reduces the reinforcing and subjective effects of heroin in heroin-dependent volunteers. Psychopharmacology (Berl) 2005;181:664–675.
    1. Rothman R, Ni Q, Xu H. Buprenorphine: a review of the binding literature. In: Cowan A, Lewis J, editors. Buprenorphine: Combatting Drug Abuse with a Unique Opioid. New York, NY: Wiley-Liss, Inc; 1995. pp. 19–29.
    1. Bickel WK, Amass L, Crean JP, Badger GJ. Buprenorphine dosing every 1, 2, or 3 days in opioid-dependent patients. Psychopharmacology (Berl) 1999;146:111–118.
    1. Walsh SL, June HL, Schuh KJ, Preston KL, Bigelow GE, Stitzer ML. Effects of buprenorphine and methadone in methadone-maintained subjects. Psychopharmacology (Berl) 1995;119:268–276.
    1. Resnick RB, Kestenbaum RS, Washton A, Poole D. Naloxone-precipitated withdrawal: a method for rapid induction onto naltrexone. Clin Pharmacol Ther. 1977;21:409–413.
    1. Loimer N, Schmid RW, Presslich O, Lenz K. Continuous naloxone administration suppresses opiate withdrawal symptoms in human opiate addicts during detoxification treatment. J Psychiatr Res. 1989;23:81–86.
    1. Mendelson J, Jones RT, Welm S, Brown J, Batki SL. Buprenorphine and naloxone interactions in methadone maintenance patients. Biol Psychiatry. 1997;41:1095–1101.
    1. Hämmig R. Einleitung einer Substitutionsbehandlung mit Buprenorphin unter vorübergehender Überlappung mit Heroinkonsum: ein neuer Ansatz (“Berner Methode”). [Induction of a buprenorphine substitution treatment with temporary overlap of heroin use: a new approach (“Bernese Method”)] Suchttherapie. 2010;11:129–132. German.
    1. Meissner W, Leyendecker P, Mueller-Lissner S, et al. A randomised controlled trial with prolonged-release oral oxycodone and naloxone to prevent and reverse opioid-induced constipation. Eur J Pain. 2009;13:56–64.
    1. Gossop M. The development of a Short Opiate Withdrawal Scale (SOWS) Addict Behav. 1990;15:487–490.
    1. Vogel M, Dürsteler-MacFarland KM, Walter M, et al. Prolonged use of benzodiazepines is associated with childhood trauma in opioid-maintained patients. Drug Alcohol Depend. 2011;119:93–98.
    1. Lingford-Hughes A, Welch S, Peters L, Nutt D. BAP updated guidelines: evidence-based guidelines for the pharmacological management of substance abuse, harmful use, addiction and comorbidity: recommendations from BAP. J Psychopharmacol. 2012;26:899–952.
    1. Nordt C, Vogel M, Dürsteler KM, Stohler R, Herdener M. A comprehensive model of treatment participation in chronic disease allowed prediction of opioid substitution treatment participation in Zurich, 1992–2012. J Clin Epidemiol. 2015;68:1346–1354.
    1. Hess M, Boesch L, Leisinger R, Stohler R. Transdermal buprenorphine to switch patients from higher dose methadone to buprenorphine without severe withdrawal symptoms. Am J Addict. 2011;20:480–481.

Source: PubMed

Szponzorok és közreműködők

Egészségi állapot

Kábítószer-beavatkozások

3
Iratkozz fel