Instrumentos de recolección de datos Prueba de entrada (Pre-test)

Buprenorphine,apartial α-opioidagonistthat isFDAapprovedinaninjectableform

(Buprenex)forthetreatmentofpain,has recentlybeenapprovedasadetoxification agentandforopioidmaintenancetreatmentas analternativetomethadonemaintenance.A numberofclinicaltrialshavereportedittobe effectiveforheroindetoxification(Beckeretal. 2001;Bickeletal.1988;Diamantetal.1998), andthemedicationshouldplayanimportant roleingraduallyremovingpatientsfrom methadonemaintenance(Amassetal.2004; Banysetal.1994;Johnsonetal.2000).

Buprenorphine is available in oral form as Subutex, which contains only buprenorphine, and is meant for patients who are starting treatment for drug dependence. Another form, Suboxone, contains buprenorphine and naloxone and is intended for persons depen- dent on opioids who have already started and are continuing medication therapy.

Buprenorphine has great affinity for the

:-opioid receptor, in spite of being only a partial agonist, and

can displace other

One advantage of

buprenorphine is

that it can be

dispensed at a

physician’s office,

unlike methadone,

which can be

dispensed only at

designated treat-

ment centers.

in. This feature gives buprenorphine the ability to precipitate opioid withdrawal when administered to patients who have recently used heroin (Kosten and

McCance-Katz 1995). An advantage to buprenorphine is its safety. Because of the partial agonist action, buprenor- phine has a “ceiling effect” with regard to overdose potential (Walsh et al. 1994). That is, unlike methadone, which produces increasing

respiratory suppression with increasing dose, respiratory effects of buprenorphine tend to level off due to its partial agonist action. Another advantage of buprenorphine is that it can be dispensed at a physician’s office, unlike methadone, which can be dispensed only at designated treatment centers. This makes access to this medication for opioid dependence much more convenient for both patient and clinician. See TIP 40, Clinical Guidelines for the Use of Buprenorphine in the Treatment of Opioid Addiction (CSAT 2004a).

Unlike methadone, buprenorphine may be prescribed by physicians who are not con- nected with a certified opioid treatment pro- gram. However, there is a still a specific

training and certifi- cation process physicians must undergo in order to prescribe the medi- cation. Information on the legal aspects of prescribing buprenorphine and rules for carrying out detoxification in the physician’s office can be found at http://

www.buprenor- phine.samhsa.gov/. Information given at the site includes the following on the Drug Addiction TreatmentAct (DATA)of2000: “[DATA2000] expandstheclinical contextofmedica-

Inpatient

treatment can

provide additional

support, medical

supervision, and

rehabilitative

treatment that

serve as

disincentives to

relapse.

tion-assistedopioidaddictiontreatmentby allowingqualifiedphysicianstodispenseor prescribespecificallyapprovedScheduleIII, IV,andVnarcoticmedicationsforthetreat- mentofopioidaddictionintreatmentsettings otherthanthetraditionalOpioidTreatment Program(i.e.,methadoneclinic).Inaddition, DATA2000reducestheregulatoryburdenon physicianswhochoosetopracticeopioidaddic- tiontherapybypermittingqualifiedphysicians toapplyforandreceivewaiversofthespecial registrationrequirementsdefinedinthe ControlledSubstancesAct”(SAMHSA2002).

Terminating

Methadone

Maintenance

Treatment

Individualsseekingthediscontinuationof methadonemaintenancerequireamuchmore lengthydetoxificationprocessthanthat

describedaboveforheroin.Themethadone doseshouldbetaperedgraduallyby5to 10mg/weekuntiladailydoseof30to40mghas beenattained.Atthattime,detoxificationwith eitherclonidineorsmallerdosesofmethadone canbeinstituted.Theuseofclonidinehasthe advantageofbrevityasacompleteclonidine detoxificationusuallycanbeconductedwithin 2to3weeks(Goldetal.1984).

Once the daily dose requirement has been established by using the principles outlined above, the patient can be placed on a stand- ing dose of clonidine. The dose required usu- ally is in the range of 0.2mg, three to four times daily, although titration (adjustment of dosage in light of drug response) is necessary based on the information gathered during the clinical examination. Additional doses as needed (sometimes abbreviated “PRN”) of 0.2mg clonidine also can be given and blood pressure parameters must be followed prior to the administration of standing and PRN doses to avoid orthostatic hypotension. The initial standing dose can be reduced to 0.1mg, given three to four times daily, after one week of detoxification, with PRN doses of 0.1mg available. After a period of 1 week on this reduced dosage, clonidine is given for an additional week only if needed. Because cloni- dine does not reverse all opioid withdrawal symptoms, especially insomnia, adjunctive medications for symptom relief of insomnia, nausea, diarrhea, etc. usually are required. Clonidine detoxification is best conducted on an inpatient basis to ensure appropriate vital sign monitoring. Inpatient treatment also reduces the impulse to relapse, especially if the detoxification is difficult.

Methadone detoxification can be continued once a daily dose of 30 to 40mg is achieved, as described above. The dose can be reduced to 20mg per day by a reduction of 5 to

10mg/week. Once the patient is on 20mg/day, methadone can be reduced by 1 to 2mg daily, depending on clinical measures of withdraw- al. As with clonidine detoxification, the final 2 to 3 weeks of methadone detoxification is associated with recidivism (relapsing).

Inpatient treatment, if available, can provide additional support, medical supervision, and rehabilitative treatment that serve as disin- centives to relapse.

Rapid

and

Ultrarapid