Rush Limbaugh is not alone in his abuse of prescription pain medicine an estimated 9 million Americans are current users of prescription drugs for non-medical reasons, according to the National Institute of Drug Abuse.
Now there is a newly available medication an opiate with special characteristics called buprenorphine. The medication was recently approved by the FDA as a detoxification and maintenance treatment for addiction to opiates such as Oxycontin, Percocet, and heroin. P&S's Department of Psychiatry is among the first places in New York to offer the new treatment option. The program also educates primary care physicians who are allowed to prescribe the medication after completing a training course.
"Many people start out with legitimate problems, such as lower back pain, but become dependent and continue to use the medication after the pain is gone," says Dr. David M. McDowell, assistant clinical professor of psychiatry and director of the Columbia Buprenorphine Program.
Buprenorphine seems to have a treatment advantage over methadone, the more traditional detox and maintenance drug, for a variety of reasons. It is difficult to overdose on buprenorphine and it is hard to use increasingly high doses because the drug has a ceiling effect. Taking too much of the drug works to antagonize itself and shuts down the cell's opiate-receptor system, which can push the person into withdrawal. It is one of the few drugs that has this mechanism of action.
It is possible, however, to overdose on methadone. The new treatment also is preferable to methadone for some people because it can be administered and prescribed in a doctor's office, rather than in a methadone clinic, which is less convenient and more restrictive.
"Buprenorphine is suitable for people who, even though they have a substance abuse problem, are employed and have continued family ties, for example. Methadone is more suitable for people who need a more structured environment and more supervision," says Dr. Herbert D. Kleber, professor of psychiatry and director of the New York State Psychiatric Institute's Division on Substance Abuse.
"Methadone clinics also carry a stigma that they are only for hardcore heroin addicts. The stigma deters people who still hold jobs from wanting to sit in a methadone clinic waiting room," says Dr. McDowell, who is also senior medical adviser and founder of the substance treatment and research service (STARS) of the New York State Psychiatric Institute. The other members of the Buprenorphine Program are Dr. Erik Gunderson, medical director, and Roberta Sales, nurse coordinator.
Columbia decided to launch the Buprenorphine Program because starting people on the drug requires a certain amount of expertise, which the physicians in the Department of Psychiatry's Substance Abuse Division can provide. It is best for patients to start taking buprenorphine when they are in the early stages of withdrawal. Once on the drug, the Columbia program can refer patients to doctors certified to prescribe it or the patients can continue their treatment at Columbia.
Buprenorphine has been used as pain medication for years in hospitals, and a few researchers, including Dr. Kleber, had permission from the federal government to use it experimentally in addiction treatment studies. Methadone has been the only drug that doctors could prescribe for opiate addiction treatment for decades. The federal government's limitations on opiates started about a century ago, first with the Pure Food and Drug Act of 1906 and then the Harrison Narcotic Act of 1914. In 2000, Congress relaxed the restrictions and permitted office-based prescribing to addicts. Buprenorphine became the first drug to qualify under the Congressional act when the FDA approved it for addiction treatment in 2002.
Doctors must take an eight-hour training session and register with the Secretary of Health to be certified to prescribe the drug. Each approved doctor can provide it to a maximum of 30 patients, a way to prevent so-called "Medicaid mills" from overprescribing the drug to increase revenue for the doctor.
In this way, "the federal government is trying to avoid a few greedy physicians from starting practices with very large numbers of buprenorphine patients, a setting in which individual needs would not be assessed or met properly," Dr. McDowell says.
Another control mechanism in place is that physicians can prescribe either of two pill forms of the drug buprenorphine alone or combined with naloxone, a counteractive drug that blocks buprenorphine in some conditions.
Naloxone does not interfere with buprenophine when the pills are placed under the tongue. But, if the combination is sold on the street, ground up and injected, the naloxone blocks buprenorphine's action and the person will go into immediate withdrawal, a condition that is rarely life-threatening but is extremely painful, Dr. McDowell says. It is hoped that this form of the drug will prevent it from being resold on the street.
The Columbia program has only been open several weeks, but has already served over a dozen patients. "The program team is looking to educate physicians about this exciting option and to create more resources for our patients in the community," Dr. McDowell says. The group is planning research projects on the best ways to get people started on the drug and investigating the best and safest methods to detoxify and maintain patients.
"We also want to study the best methods for getting people off buprenorphine entirely," Dr. Kleber says.