Buprenorphine - SUBUTEX
Buprenorphine (Subutex) is a partial agonist. It is a sublingual medication, placed under the tongue to dissolve. It has properties of both agonists and antagonists at the opiate receptor site. This pharmacological profile means that buprenorphine has a lower re-enforcing potential than agonists such as heroin and therefore a lower street value and a lower abuse potential.
Buprenorphine is a semi synthetic derivative of opium, considered a partial agonist and antagonist (Agonists – Such as Methadone and Morphine bind to Morphine receptors in the nervous system, which produce affects such as euphoria and analgesia, with side effects such as respiratory depression) (Antagonists – Such as Naltrexone, displace the Agonist and therefore block the effect of the agonist).
Because of its prolonged half life when compared with other opiates it is possible to take buprenorphine every 2-3 days without getting too many withdrawal symptoms.
It is available in 0.4, 2 and 8 mg tablets, administered via the sub-lingual route (Under the tongue), and is effective after 90-120 minutes.
Licensed for 2-4 mg on day 1, however for a more severe withdrawal syndrome there are protocols (NDAS and Brent, Kensington, Chelsea and Westminster) which suggest it is more effective increasing this to 8 mg on day 1.
Buprenorphine is particularly safe in overdose.
Fatal respiratory depression is extremely rare if used alone due to the antagonist activity preventing the usual effects of overdose
It is licensed in the UK for the treatment and management of Opiate dependency.
Some world leading institutions like FDA and its parent Department of Health and Human Services recommended that the Drug Enforcement Administration (DEA) in USA, based on the potential for abuse of buprenorphine place it, in Schedule III under the Controlled Substances Act (CSA). Buprenorphine is considered to have less risk for causing psychological and or physical dependence than the drugs in Schedule II such as morphine, oxycodone, fentanyl, or methadone .
Pre-Buprenorphine administration procedure
Prior to any Buprenorphine administration the following process must be adhered to:
• Assessment process completed and key worker allocated to patient.
• A positive Opiate urine samples must be obtained from the patient.
• Full explanation of treatment given to patient by the unit medical/ nursing staff.
• A treatment plan must be devised and agreed between the detox team and the patient.
• The initial dose of Buprenorphine should not be given until at least 6 hours after the last use of Heroin, 24 hours+ after last use of Methadone and or when mild withdrawal signs are observed.
• Patients’ baseline blood pressure and pulse must be established.
• Detox staff must complete withdrawal signs and symptom checklist with the Patient to establish severity of withdrawal syndrome.
• A full titration will be completed on all patients commencing treatment.
Procedure for Buprenorphine administration
It can take up to three days for patients to settle comfortably to their required dose during titration.
When administering Buprenorphine the following should be adhered to:
• Medication should only be administered (especially during titration) if the patient can attend for an adequate period of observation.
• Tablets must be consumed by the patient
• The dose can be increased to a maximum of 32mg depending on the patient’s symptoms, but not exceeding 8mg day 1 or 16mg on day 2. Maximum doses of 32mg are rarely necessary.
Doses given will be measured against:
o The objective observation of the patient’s withdrawal signs.
o Clinical observations (BP & Pulse).
o Patient subjective reporting of Withdrawal symptoms.
Buprenorphine Reduction/Detoxification
Once the patient’s titration and stabilization period has been completed they will commence a 12-21 day reduction regime for detoxification.
The patient’s reduction regime may be adjusted depending on their response to treatment and clinical judgement.
Buprenorphine is also an appropriate medication for maintenance treatment and will be covered in the Maintenance Section of this document.
Symptomatic Relief for Buprenorphine Detoxification
Due to the pharmacological properties of Buprenorphine, withdrawal is usually less severe than withdrawal from other opiates, reducing the need for symptomatic prescribing.
However, in some cases symptomatic relief is required during the detoxification period to reduce persistent withdrawal symptoms. This will be reviewed on an individual patient basis.
The medications that may be prescribed as symptomatic relief will include: Buscopan, Metoclopramide, Lofexidine, Voltarol, low doses of short acting benzodiazepines, and/or hypnotics.
All the above mentioned medications will be prescribed on an individual basis, in the lowest possible therapeutic doses, for short term use only.
Buprenorphine is a semi synthetic derivative of opium, considered a partial agonist and antagonist (Agonists – Such as Methadone and Morphine bind to Morphine receptors in the nervous system, which produce affects such as euphoria and analgesia, with side effects such as respiratory depression) (Antagonists – Such as Naltrexone, displace the Agonist and therefore block the effect of the agonist).
Because of its prolonged half life when compared with other opiates it is possible to take buprenorphine every 2-3 days without getting too many withdrawal symptoms.
It is available in 0.4, 2 and 8 mg tablets, administered via the sub-lingual route (Under the tongue), and is effective after 90-120 minutes.
Licensed for 2-4 mg on day 1, however for a more severe withdrawal syndrome there are protocols (NDAS and Brent, Kensington, Chelsea and Westminster) which suggest it is more effective increasing this to 8 mg on day 1.
Buprenorphine is particularly safe in overdose.
Fatal respiratory depression is extremely rare if used alone due to the antagonist activity preventing the usual effects of overdose
It is licensed in the UK for the treatment and management of Opiate dependency.
Some world leading institutions like FDA and its parent Department of Health and Human Services recommended that the Drug Enforcement Administration (DEA) in USA, based on the potential for abuse of buprenorphine place it, in Schedule III under the Controlled Substances Act (CSA). Buprenorphine is considered to have less risk for causing psychological and or physical dependence than the drugs in Schedule II such as morphine, oxycodone, fentanyl, or methadone .
Pre-Buprenorphine administration procedure
Prior to any Buprenorphine administration the following process must be adhered to:
• Assessment process completed and key worker allocated to patient.
• A positive Opiate urine samples must be obtained from the patient.
• Full explanation of treatment given to patient by the unit medical/ nursing staff.
• A treatment plan must be devised and agreed between the detox team and the patient.
• The initial dose of Buprenorphine should not be given until at least 6 hours after the last use of Heroin, 24 hours+ after last use of Methadone and or when mild withdrawal signs are observed.
• Patients’ baseline blood pressure and pulse must be established.
• Detox staff must complete withdrawal signs and symptom checklist with the Patient to establish severity of withdrawal syndrome.
• A full titration will be completed on all patients commencing treatment.
Procedure for Buprenorphine administration
It can take up to three days for patients to settle comfortably to their required dose during titration.
When administering Buprenorphine the following should be adhered to:
• Medication should only be administered (especially during titration) if the patient can attend for an adequate period of observation.
• Tablets must be consumed by the patient
• The dose can be increased to a maximum of 32mg depending on the patient’s symptoms, but not exceeding 8mg day 1 or 16mg on day 2. Maximum doses of 32mg are rarely necessary.
Doses given will be measured against:
o The objective observation of the patient’s withdrawal signs.
o Clinical observations (BP & Pulse).
o Patient subjective reporting of Withdrawal symptoms.
Buprenorphine Reduction/Detoxification
Once the patient’s titration and stabilization period has been completed they will commence a 12-21 day reduction regime for detoxification.
The patient’s reduction regime may be adjusted depending on their response to treatment and clinical judgement.
Buprenorphine is also an appropriate medication for maintenance treatment and will be covered in the Maintenance Section of this document.
Symptomatic Relief for Buprenorphine Detoxification
Due to the pharmacological properties of Buprenorphine, withdrawal is usually less severe than withdrawal from other opiates, reducing the need for symptomatic prescribing.
However, in some cases symptomatic relief is required during the detoxification period to reduce persistent withdrawal symptoms. This will be reviewed on an individual patient basis.
The medications that may be prescribed as symptomatic relief will include: Buscopan, Metoclopramide, Lofexidine, Voltarol, low doses of short acting benzodiazepines, and/or hypnotics.
All the above mentioned medications will be prescribed on an individual basis, in the lowest possible therapeutic doses, for short term use only.