A new approach to emergency department treatment for opioid-addicted patients is the implementation of a drug called Suboxone, which contains buprenorphine and naloxone. Previously, Suboxone did not contain naloxone and only buprenorphine, ultimately leading to the intravenous abuse of buprenorphine, which I will explain later.
To start, the mechanism for buprenorphine is a partial agonist and partial antagonist for the mu receptor, which is where endorphins bind. Likewise, outside opioids, such as heroin, are considered full agonists, binding all the mu receptors, causing the induced effects. Buprenorphine induces a decreased effect, or a 'ceiling effect,' in which all the mu receptors are activated, but only to a certain extent. As a result, some of the effects, like euphoria, are still present, but others, like respiratory depression, are not, or are decreased (Lutfy & Cowan, 2004). This seems to be promising in treatment of opioid overdose related fatalities. Furthermore, an increase in concentration of buprenorphine will not increase the effects, like heroin would, due to the very high affinity buprenorphine has for the mu receptors (Walsh & Eissenberg, 2003).
The issue occurred in that drug-users were now abusing buprenorphine, by intravenous use. Although the effects would not be as much as something like heroin, buprenorphine could be prescribed as covered by insurance. As a result, Suboxone now adds naloxone, an opioid antagonist, to prevent further abuse and diversion (Yokell et al., 2011).
What is now starting to be implemented is the use of Suboxone as part of emergency medicine treatment for IVDU patients who present with opioid-related issues. With the safe alternative of Suboxone, a myriad of physiological side effects can be controlled, including fatal respiratory depression and withdrawal symptoms.
With this being a relatively new practice among emergency departments, Denver Health Adult Emergency Department has been approved to conduct research on the matter beginning this year.
References
Bankowitz, R. (2017). Addressing America’s Opioid Epidemic. The New York Times. Retrieved from https://www.nytimes.com/2017/09/21/opinion/opioid-addiction.html?mcubz=0
Lutfy, K., & Cowan, A. (2004). Buprenorphine: a unique drug with complex pharmacology. Current neuropharmacology, 2(4), 395-402.
Sinnenberg, L. E., Wanner, K. J., Perrone, J., Barg, F. K., Rhodes, K. V., & Meisel, Z. F. (2017). What factors affect physicians' decisions to prescribe opioids in emergency departments? SAGE Journals, 2(1). doi:10.1177/2381468316681006
Walsh, S. L., & Eissenberg, T. (2003). The clinical pharmacology of buprenorphine: extrapolating from the laboratory to the clinic. Drug and alcohol dependence, 70(2), S13-S27.
Yokell, M. A., Zaller, N. D., Green, T. C., & Rich, J. D. (2011). Buprenorphine and Buprenorphine/Naloxone Diversion, Misuse, and Illicit Use: An International Review. Current Drug Abuse Reviews, 4(1), 28-41.
It is very true and very sad that the United States is currently in such an Opioid Crisis. According to the New York Times Article "Short Answers to Hard Questions About the Opioid Crisis", it is the deadliest drug crisis in American history. With that being said, this drug Suboxone potentially seems to be promising for medication assisted treatment for opioid dependence. After doing some research, I found an interesting handout from UVM Department of Family Medicine entitled "Medication Assisted Opioid Treatment and Your Oral Health". This is regarding Suboxone and Oral Health (which is of interest in me since I want to attend Dental School). It is very common among opioid users to have poor oral health due to a number of lifestyle factors such as high rates of tobacco and alcohol use, poor nutrition and overall poor dental hygiene. So on top of all of these risk factors already prevalent among opioid users, Suboxone in particular can lead to dental erosion. This is because Suboxone is acidic and administered as a sublingual film or tab. This creates an acidic oral environment leading to dental erosion. Oral Health is incredibly important and there are steps that can be taken to ensure that someone who is taking Suboxone can maintain a healthy mouth. I was intrigued to read this Blog Post and find how it relates to Oral Health. Thanks Pat!
ReplyDeleteSimilar drugs were created to help treat people with alcohol addictions (like antabuse/disulfiram). An alcohol abuser need only take this drug daily and if he or she tried to drink, severe vomiting would be induced. However, this drug failed for one simple reason - people wouldn't take it (Drugs, 2017). Unfortunately, a lot of drug rehabilitation is dependent on an addict's decision to make a change, even when their brain chemistry has been rewired to abuse a substance. I wonder if it might be a more productive avenue for drug research to come up with a cost-effective pain killer that is not as addictive as opioid-based products.While opioids have been abused in the US since the 1800's the levels we see now are the result of people who were prescribed opioids for acute, non-life threatening pains who then became addicted to their medication. The reason we are at epidemic levels is because so many people were exposed via prescribed medication to something that is highly addictive (Moghe,2016). For this reason, it may be easier to find a less addictive pain reliever that could prevent some addictions in the first place.
ReplyDeleteDrugs.com (Ed.). (n.d.). Antabuse - FDA prescribing information, side effects and uses. Retrieved October 03, 2017, from https://www.drugs.com/pro/antabuse.html
Moghe, S. (2016, October 14). Opioids: From 'wonder drug' to abuse epidemic. Retrieved October 03, 2017, from http://www.cnn.com/2016/05/12/health/opioid-addiction-history/index.html
The opioid epidemic is one that I witnessed first hand while working as a scribe in two emergency departments in Arizona. I can recall almost every shift having a patient that was either seeking a opioid prescription refill, under the influence of the medications, or experiencing withdrawal symptoms that they could no longer handle. My experiences with these patients and the treatments they received differed among each emergency physician that I worked with, with some prescribing them enough that the patient was satisfied with their “treatment” or were refused the medications and left against medical advice. With your article about Suboxone being used to help relieve withdrawal symptoms as well as decrease the effects of the opioids themselves with addition of Naloxone, I correlate it with the use of the methadone. Methadone is also used to help those with opioid addiction and is typically prescribed to those trying to detox from the use of opioids and narcotics (drugs.com). Though this can be helpful to those trying to detox, it is also still an opioid and with abuse can lead to its own kind of addiction though the drug does not cause the “high” associated with other opioids (drugs.com). With this being the case, I am curious to see how the treatment of opioid addiction with Suboxone differs or correlates with trends I saw of patients using Methadone for their addiction.
ReplyDeleteReferences:
Drugs.com, (2017, September 4) Methadone. Retrieved from https://www.drugs.com/methadone.html
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ReplyDeleteI witnessed a significant amount of opioid abuse at work in Baltimore, where some statistics estimate as many as 1 in 10 residents are addicted to heroin. I had the opportunity to work both in the ER in the city and also at a primary care provider's office who prescribed Suboxone, where I witnessed its effects first hand. While it's easy to get excited about its benefits, there is the potential for problems as well. The risk of abuse is very real, and the addition of naloxone was a HUGE step in combating this. It is also important to consider providing a drug like Suboxone in a ER setting may have cause long-term effects on healthcare in general. Many argue that this causes a dependency on the ER for medications which need to be monitored closely.
ReplyDeleteIn Maryland, regulations requiring regular counseling and frequent drug tests for those who used Suboxone, and special certifications and regulations of the physicians who prescribed it were common. These additional steps are vital in maintaining that Suboxone is prescribed and used in an ethical way, but they should not scare people away. It is important to keep in mind that the benefit it provides is life-changing. I think this is a really great topic- good luck with your grant!
Thanks for sharing this information Pat. Suboxone seems to be a very promising tool to combat the rising opioid use in the United States. When reading this blog I was immediately reminded of a video about narcan shown in my EMT class. This video was shown to us just prior to our training on how to administer narcan intranasally. The video talked about how Chicago has been giving away naloxone for years and have noticed a dramatic decrease in opioid overdose fatalities. I was able to find it again and post it a link below. I also found an article that states that Washington state has created safe injection locations where citizens can perform intravenous drug use with government provided sterilized needles. This seems incredible desperate to me but it also shows how desperate this country is to find solutions.
ReplyDeletehttp://www.chicagotribune.com/77045929-157.html
http://www.chicagotribune.com/news/opinion/chapman/ct-chapman-opioids-overdose-heroin-perspec-0427-jm-20170426-column.html