Buprenorphine for Pain and
David A. Moltz, MD
MAPP Clinical Conference
April 30, 2010
I. Addiction and Dependence
A maladaptive pattern of substance use, with 3 or more of:?Tolerance
?Using larger amounts or for a longer time than intended?Persistent desire or lack of control
?A great deal of time spent obtaining, using, recovering from
?Important activities given up
?Continued use in spite of negative consequences
A chronic but treatable brain disease characterized by
?loss of control
?use despite known harm
Dependence vs Addiction?Addiction may occur with or without the presence of physical dependence. ?Physical dependence results from the body?s adaptation to a drug or medication and is defined by the presence of –Tolerance and/or
Opioid Use in a Household Survey
?According to the 2002 National Survey on Drug Use and Health : An estimated
4.4 million persons were current users of pain relievers for nonmedical purposes.?New non-medical pain reliever use more than quadrupledfrom 1990 (628,000 new users) to 2000 (2.7 million new users).
SOURCE: SAMHSA, 2002.
Neural circuitry of reward
?Present in all animalsProduces pleasure for
behaviors needed for
Neural circuitry of reward
the same circuitry
Gen Psychiatry 2009;66(4):355-365Meeks TW, Jeste DV. The neurobiology of wisdom.
Definition of Terms?Agonist?Antagonist?Affinity
?Novel opioid with both agonist and antagonist properties
?Partial agonist at mu opioid receptor?High affinity
?Low intrinsic activity
?Antagonist at kappa receptor
?High affinity for mureceptors ?ability to compete with full muagonists (such as heroin) and to block their effects. ?Low intrinsic activity ?feeling of well-being without full opioid effects
?Very slow dissociation rate ?prolonged therapeutic effects.
Advantages of a Partial Agonist?Lower abuse potential
?Lower level of physical dependence?Relative safety if ingested in overdose quantities
?Weak opioid effects compared with methadone.
?Buprenorphine has tight binding to and slow dissociation from opioid receptors. It produces a blockade effect at the mu-opioid receptor so that subsequently administered opioids do not produce their full euphoric effect.
?It appears to produce less physical dependence than a full opioid agonist (such as methadone), and it may be easier to discontinue at the end of medication treatment.
AddictionIII. Buprenorphine for
Drug Addiction Treatment Act of
2000 (DATA 2000)
?Expands treatment options to include both the general health care system and opioid treatment programs.
–Expands number of available treatment slots–Allows opioid treatment in office settings–Sets physician qualifications for prescribing the medication
?Blocks cravingBlocks opiate withdrawal Does not produce a ?high?Blocks the effects of other opioidsMilder withdrawal than methadoneStabilization of brain functionAnti-depressant / anti-anxiety effect
?Significant enhancement in treatment retention and in the quality of participation
?Mainstreaming of opioid dependence treatment with office-based practice?Greater safety
?Lower diversion risk
ResearchOutcomes ?Buprenorphine is as effective as moderate doses of methadone.
?Partial agonist effects make it mildly reinforcing, encouraging medication compliance.
?After a year of buprenorphine + counseling, 75% of patients were retained in treatment compared to 0% in a placebo + counseling condition.
?Available evidence in patients maintained on buprenorphine indicates no clinically significant disruption in cognitive and psychomotor performance.
?“Long-term use…does not impair driving ability.”Dagtekin O, et al. Assessing cognitive & psychomotor Performance under long-term treatment with transdermal buprenorphine in chronic noncancer pain patients. Anesth Analg 2007;105:1442-8
?Buprenorphine + naloxone
?Partial agonist + pure antagonist
?Naloxone is only active intravenously
?Will precipitate withdrawal in opioid-dependent individuals
?Combination decreases diversion risk
Addiction is not a disease of the
IV. Buprenorphine and Pain
Pain Patients vs Addicted Persons
?Consequence of inadequate treatment of pain
?May be indistinguishable from addictive behavior
Effectiveness in Pain
?30-40 times more potent than morphineCeiling effect ?high safety profileTransdermal used extensively in Europe “…transdermal buprenorphine provides effective, sustained and dose-dependent analgesia, irrespective of age.”
Pergolizzi J et al. Opioids & the management of chronic severe pain in the elderly: Consensus statement of an international expert panel. Pain Practice 2008;8(4):287-313
Buprenorphine vs Morphine?Chronic cancer pain
?More effective than morphine for physical pain, mental health and quality of life.
Pace, MC, et al. Buprenorphine in long-term control of chronic pain in cancer patients. Frontiers in Bioscience 2007;(12):1291-1299
Buprenorphine vs Methadone?Post-partum, maintained on buprenorphine or methadone, with opioids or ibuprofen as needed
?Buprenorphine group decreased ibuprofen use over 5 days
?Methadone group increased ibuprofen use
Jones HE, et al. Management of acute postpartum pain in patients maintained on methadone or buprenorphine during pregnancy. Am J Drug and Alcohol Abuse, 2009; 35:151-56
Managing Pain During
Buprenorphine Maintenance?Supplement with NSAIDS
?Temporarily replace buprenorphine with opiates?Override buprenorphine with opiates
?Divide +/or increase buprenorphine doseHeit HA, Gourlay DL. Buprenorphine: New tricks with an old molecule for pain management. Clin J Pain2008; 24(2):93-97
?A decrease in the threshold to elicit pain?A state of nociceptive sensitization?Hyperesthesia
The generation of pain in response to low-intensity stimuli or stimuli that are not normally painful.
Mechanisms of Hyperalgesia?NMDA (glutaminergic)
?Dynorphin (kappa receptor agonist)
?Peripheral, spinal and central sensitization?“More complexity than clarity”
Opioid-Induced Hyperalgesia?May be activation of hyperalgesic systems to counteract the analgesic effects of the opioids
?Ex: Morphine activates NMDA receptors and spinal dynorphin
?In withdrawal, the hyperalgesic system is unopposed
Hyperalgesia and Tolerance?May share mechanisms (eg,NMDA), but they are clinically different
?Hyperalgesia is increased sensitivity to pain
?Tolerance is decreased sensitivity to opioids
Chang G, et al. Opioid tolerance & hyperalgesia. Med Clin N Am2007;91;199-211
OIH and Tolerance
?Difficult to differentiate clinically
?OIH ?diffuse, generalized pain, often different from pre-existing pain
?Stopping the opioid can differentiate–Tolerance ?more pain
–OIH ?less pain
?Minimize opioid dose using adjuvant therapies
?Methadone (NMDA antagonist)?Buprenorphine
Pain reduction after detoxification?23 patients not getting benefit from high-dose opioids
?No addictive behaviors
?21 showed marked decrease in pain after detoxification
?After weaning, 63% decrease in pain with buprenorphine vs. 47% without
Baron MJ, McDonald PW. Significant pain reduction in chronic pain patients after detoxification from high-dose opioids. J Opioid Management2006;2(5):277-282
?Buprenorphine relieves allodynia from neuropathic pain
?Blocks hyperalgesia due to central hypersensitization
?Kappa antagonist (dynorphin)
?“Buprenorphine has been shown to have a pronounced antihyperalgesic effect.”
Induru RR, Davis MP. Buprenorphine for neuropathic pain –Targeting hyperalgesia. Am J Hospice & Palliative Med2009:26 (6);470-3
Likar R. Transdermal buprenorphine in the management of persistent pain –Safety aspects. Therapeutics & Clinical Risk Management2006:2(1):115-125
Buprenorphine and OIH
?“Resolution of OIH usually follows quickly during the maintenance phase with buprenorphine.”
?“Buprenorphine may be unique in its ability to treat chronic pain and possibly OIH”?Silverman SM. Opioid induced hyperalgesia: Clinical implications for the pain practitioner.
Prescription Opioid Addiction Treatment Study (POATS)?Opioid dependence
?42% with co-existent chronic pain
?Overall, 49% substantially improved after 3 mo of buprenorphine
?Of those with chronic pain, 53%
substantially improved, and “many had significant improvement in their pain.”Weiss R. NIDA Blending Conference 4/22/10. www.NIDA.NIH.Gov
Coexistent Addiction and Pain?Buprenorphine is ideal
?Clinical Guidelines for the Use of Buprenorphine in the Treatment of Opioid Addiction.
SAMHSA/CSAT Treatment Improvement Protocols. TIP 40.
?http://www2.aaap.org/buprenorphine (For DATA training)