Thursday, April 26, 2012

Buprenophine and BuTrans Patches

Last night I attended a superb dinner presenation by Dr. Owen Williamson arranged by Chris Szado, the pharmacological representative for Bu Trans.  Buprenorphine is a partial agonist opioid that has been extremely successful as an alternative to methadone in select populations for addiction therapy. It's also been used for moderate pain control with less concern for addiction. .One of the main advantages of patch technology like Bu Trans is that it can't be diverted. Pills like oxycontin were being crushed and injected by heroin users but this is not the case with Bu Trans.  Indeed Oxycontin , dubbed Hillybilly Heroin, has been removed and replaced by OxyNeo, the exact same drug but in a formulation that does not allow the pill to be crushed and used for injection.  Oxyneo in contrast to Oxycontin turns into an insoluble gel with crushing and heating so is a breakthrough development we can all be thankful to the pharmacology company for developing.
Bu Trans  advantage pharmacologically especially for pain is that it results in slow steady release  through skin absorption - and less fluctuations in dosage than oral preparation.  Patches can be worn for a week at a time so the whole problem of missing dosage or taking too many pills at once is simply bypassed.
Dr. Owen Williamson is an Orthopedic Surgeon from Australia who specialized in spinal surgery then became a leader in pain medicine in Australia. He'd used buprenorphine there years and had 7 years experience with the buprenophine patches before coming to Canada where he works specifically as a Pain Specialist.  Canada doesn't have a subspeciality of pain medicine yet so most of us there tonight were indeed Addiction Medicine specialists who were pain specialists as a consequence of our work with addiction.
Appropriate narcotic treatment of pain doesn't  lead to addicition however addicts commonly had pain and presented with pain to address their addiction issues.. Indeed many of us were there tonight to ask Dr. Williamson's advise on how best to manage pain in our addicted patients.  Often despite being on methadone and having their addiction controlled with methadone patients have pain and this needs to be addressed.
After the presentation during a lovely meal provided by the excellent Market Restaurant on Georgia we had ample time to discuss not just individual clinical strategies but community medicine and community psychiatry in general.
There is extensive evidence based scientific research in clinical management of addiction and the appropriate treatment of pain yet authorities with distinctly different agendas and apparently often political short sighted personal aims commonly intervene with such old saws  as the 'war on drugs'.  To date the only success in that multi billion dollar tax payer kerfuffle has been the recognition of the success of the socalled 'drug courts'.  These divert addicts who committ crimes to support their addiction from jails into treatment.
All the efforts to 'police borders' or invade other countries has to date only escalated drug abuse. Filling jails with addicts has also demonstrably harmed society and created more criminality.  Miami Vice as a television show probably did more to make cocaine sexy to kids than act as a deterrent to drug abuse. The glamor is in the 'context' and it's easy to get into the 'glamour' as a user than a cop.
Of course it's extremely difficult to unhorse the white knights who have a license to kill, often come from elite families,and get to ride roughshod over all civil rights and human rights claiming to protect a child who is likely to learn about addiction from his school mates and family especially if his family were jailed rather than treated for addiction. . Thanks to scientific research there are studies that seriously question use of the Hollywood cowboy police chase because police chases have caused more  damage, maiming and  killing.  Thanks to better surveillance technology today than yesterday police can save themselves car damage and collect their suspects reasonably a day later. It's equally effective today but decidedly less glamorous. Treatment of addiction today is the gold standard.  The hope is for as many options in the treatment of addicition as we as doctors have in the treatment of diabetes.  Buprenorphine and Bu Trans are certainly welcome addictions.  My psychiatrist and addiction medicine friends in the US who have had these tools swear by them.
Dr. Gary Horvath, the Addiction Medicine specialist, whose clinic Doc Side is in  Downtown Eastside Vancouver is presently using buprenorphine on selected patients where he can assure clinical safety and is having significant success.  
So it was enjoyable to learn of how buprenorphine can be used alone for addiction and/or pain or how to switch a person from other narcotics to buprenorphine and how it is used for tapering people off narcotics whether they are being used for pain or addiction management.  There's real advantage to the Bu Trans patch being used when people are tapering off methadone and their dose is below 40 mg a day.  This assists them in going through the final withdrawal phase.
Dr. Owen Williamson is a very bright and accomplished young man who has extensive experience in this field as well as being decidedly witty.  I am only giving a taste of the presentation. I took notes and am including these here, just as more of a jist. I was eating the very fine Market Restaurant food while listening too the talk so will only apologise for any mistakes or mispelling.  I would indeed suggest contacting either Chris Szado with Bu Trans or Dr. Owen Williamson directly for the 'facts'.   My purpose in sharing this here is to save a reminder for  myself  and to essentially raise consciousness about advances in the incredibly rapidly developing speciality fields of addiction and pain management.
iphone 2 finger notes on notepad while eating scrumptuous food at end of long work day
Owen D Williamson
Originally orthopedic surgery then spine surgery then public health
Melbourne 3 years later pain - biggest predictor mental health 
Chronic pain and addiction
National Pain Summit yesterday
Addiction - 10%
Chronic Pain - 30%
OxyContin attraction was predictability - cost of 1 80 mg oxycontin on street same cost as 2 days heroin
67% high school students get their opioids of abuse from home
Need for use of "drug safe"1 in 5' Canadians have chronic pain
Diverters - industrial dosages of pain medicine - street value of example patients -$650,000 a year
Inquest into death of Donna Marie Bertrand
- suicide - antidepressants
- jury 32/48 recommendations related to opioids
- pharmanet - "every patient I see I get pharmanet"
BC - suboxone very good for pain and addiction
Suboxone can be used in BC if methadone contraindication
Detox and maintenance
Detox maintenance and taper
- slow
If you taper over 12 weeks twice as good as any faster regarding relapse and least relapse if taper over year
Transdermal buprenorphine - transition people from methadone to buprenorphine
Maintenance alone on heroin - Naomi study 
Cochrane reviews - more relapse on buprenorphine
30% Persisting pain after trauma
Butrans - persisting pain 
Max recommended dose 20 mcg/hr every 7 days 
In aust dose is 40
In Europe dose is 70
U receptor partial agonist
K receptor antagonist
Chronic pain doubles risk of suicide
Binds to alpha and b globulins not albumin
Hepatic not renal metabolism
Side effects of patch
Don't confuse fetanyl or durogesic patch with bu-trans patches - can lead to death 
Opioid induced hyperalgesia - this is done because of effect on glial cells
Allodynia - painful response to something not normally painful
Pain Medicine
- opioid rotation - webster
Meth to TDB conversion
- reduce meth to 40 
- apply patch 12 hr later - 35 mcg/hr
- hospital
- nosyk b et al Addiction 2012 (ePub)

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