Medpedia

Chemical Structures for Buprenorphine and Naloxone

In three previous posts I have reviewed several aspects of prescription opioid abuse including posts on epidemiology, toxicology and clinical pathways to abuse.

Given the growing numbers of individuals with prescription opioid abuse, safe and effective treatment options become increasingly important.

Opioid withdrawal can be quite painful and often leads to resumption of opioid use.  Treatment of opioid withdrawal can include non-opioid drugs or opiod drugs that target withdrawal symptoms.

Symptomatic withdrawal treatment alone results in high relapse rates.  This outcome has produced efforts to find more effective long-term treatments for prescription opioid abusers.

Short or long-term opioid substitution treatment appears to produce an incremental improvement in outcomes.  Methodone substitution or substitution with the combined drug buprenorphine and naloxone (Suboxone) provide two options for clinicians and patients.

Buprenorphine is classified as a partial opioid agonist stimulating the opioid receptor with limited euphoric effect.  Naloxone is felt to reduce the misuse of the combined drug compound by blocking/reducing euphoria with intravenous administration.

A recent study examined the effectiveness of Suboxone in a group of 653 outpatients seeking treatment for prescription opioid dependence.  The key elements of the design of this study included:
Phase one: 2-week stablization on buprenorphine-naloxone, 2-week taper and 8-week follow-up
Phase two: Individuals who relapsed after phase one entered a longer 12-week stabilization on buprenorphine-naloxone followed by a 4-week taper and 8-week follow-up
Adjunctive counseling:  Half the subjects received adjunctive counseling using a manual-based program emphasizing education, skills training and life-style modification.
Outcome Assessment:  During the follow-up period abstinence was measured by urine-test verified self report

Only 7% of subjects achieved a successful outcome by the end of phase one.  At the end of the treatment phase of phase 2, 49% of subjects were rated as having a successful outcome.  However, after phase 2 tapering successful outcome rates dropped to 9%.  Adjunctive counseling did not appear to improve outcomes in either phase.

The authors note the study supports use of Suboxone with a primary medical management approach (without a formal substance abuse counseling component) in the clinician's office.  Approximately 50% of users will experience a successful outcome during treatment with Suboxone.

However, with the high relapse rates after the taper in phase 2 of the study, the study authors note: "What length of buprenorphine-naloxone treatment, if any, would lead to substantially better outcomes during a taper?"  This study supports a longer term treatment trial using six months or a year of Suboxone treatment.

Only a minority of clinicians are certified to give Suboxone in the U.S.  It requires a specific 8 hour training course before certification.  Suboxone costs about $10 per day and this may limit it's use.  Nevertheless, it provided opioid prescription abusers and their clinicians an important treatment option.

A resource to identify physicians certified to use Suboxone in the U.S. can be found here.

Molecular structure of buprenorphine and naloxone from the PubChem Compound site.

Weiss RD, Potter JS, Fiellin DA, Byrne M, Connery HS, Dickinson W, Gardin J, Griffin ML, Gourevitch MN, Haller DL, Hasson AL, Huang Z, Jacobs P, Kosinski AS, Lindblad R, McCance-Katz EF, Provost SE, Selzer J, Somoza EC, Sonne SC, & Ling W (2011). Adjunctive counseling during brief and extended buprenorphine-naloxone treatment for prescription opioid dependence: a 2-phase randomized controlled trial. Archives of general psychiatry, 68 (12), 1238-46 PMID: 22065255