Summer House
Drug dependence is a universal public health problem of which opioid dependence, notably involving heroin and morphine are a major component. In Europe alone, there are an estimated 1.1 million intravenous drug users and the number is estimated to be at least 3 times that many in North America. The majority of these individuals remain untreated. Opioid dependence is a chronic relapsing medical condition that requires long-term treatment and patient support. In addition, many of these intravenous drug users share syringes and needles, a practice that can lead to the transmission of serious blood-borne infections including human immunodeficiency virus (HIV), hepatitis B and hepatitis C.
Currently opiate dependence treatments like methadone can be dispensed only in a few centers that focus in addiction treatment. There are not enough addiction treatment clinics to assist all patients seeking treatment. Suboxone is the first narcotic drug available under the Drug Abuse Treatment Act (DATA) of 2000 for the treatment of opiate dependence that can be prescribed by a physician. Hopefully, this advance in therapeutics will provide more patients the opportunity to access treatment.
Suboxone (buprenorphine with naloxone) is currently available for the maintenance treatment of opioid addiction. The intention of adding naloxone to the formulation is to deter intravenous misuse and reduce the symptoms of opiate dependence. Suboxone treatment is intended for use in adults and adolescents more than 16 years of age who have agreed to be treated for addiction.
Once detoxification of the individual is completed, Suboxone is used during the maintenance phase of treatment. Suboxone has recently become the drug of choice instead of methadone in the treatment of opiate addiction. Suboxone use is less rigidly controlled than methadone because it has a lower potential for abuse and is less dangerous in an overdose. As patients progress on therapy, the physician may write a prescription for a take-home supply of the medication.
Suboxone Prescription
Only those physicians who have approval from the Drug Enforcement Agency (DEA) are able to start in-office treatment and provide prescriptions for ongoing medication. The Center for Substance Abuse Treatment (CSAT) maintains an active database to help patients locate qualified doctors.
Route of Administration
Suboxone is available as a tablet which is always administered sublingually. The pill is placed underneath the tongue until it is fully dissolved. Swallowing or sucking on the pill does not offer any therapeutic benefit. When placed underneath the tongue, the pill dissolves and is absorbed in 10 -20 minutes.
Suboxone treatment is generally done under medical supervision. During the induction phase, one is taught how to properly take the medications and dose adjustments are done during the phase. One is usually started on the smallest dose until the best therapeutic effect is obtained. Once the ideal dose is obtained, the individual is seen once in a while and prescriptions can generally be available from the same physician.
Suboxone is available as 2 and 8 mg tablets. Most anecdotal reports indicate that the response to the 2 mg dose is suboptimal. The majority of individuals report benefit at higher doses of 8-16 mg. The aim of the maintenance treatment is to rid the drug craving and decrease the anxiety. The dose is usually adjusted until the drug craving features are diminished.
Since Buprenorphine is a Schedule III drug, the physician is only allowed to prescribe 5 refills in 6 months.
Maintenance therapy
Although Suboxone can be used for detoxification, its intended use is for maintenance. The ideal candidate for maintenance therapy with Suboxone is an older individual who has previously been on drugs but now has a job and wants a stable lifestyle. The individual previously has failed detoxification and wants to live a simple life without the daily cravings of his previous addiction. The majority of past drug users immediately adjust to Suboxone as the cravings disappear immediately and a smoother life style are accessible.
Suboxone Control
Because of the great potential for abuse, FDA works closely with the drug manufacturer, Reckitt-Benckiser, and other agencies to develop an in-depth risk-management plan. The FDA receives quarterly reports from the manufacturer and pharmacies and maintains a comprehensive surveillance program. This monitoring allows for early detection of abuse of the drug. The major components of the risk-management program are preventive measures and surveillance. Preventive measures instituted include drug education, tailored distribution, Schedule III control under the Controlled Substances Act (CSA), child resistant packaging and supervised dose induction. The program regularly monitors local pharmacies and web sites. Numerous other agencies also monitor the abuse of Suboxone and these include:
-Drug Abuse Warning Network (DAWN). This agency run by the Substance Abuse and Mental Health Services Administration (SAMHSA) gathers data from emergency rooms related to the illicit use of drugs or non-medical use of a legal drug.
-Community Epidemiology Working Group (CEWG). This agency monitors the use of buprenorphine.
-National Institute of Drug Abuse (NIDA). NIDA frequently sends newsletters to physicians about the addictive drugs and to report it if necessary.
Side Effects
The most common reported side effect of Suboxone includes:
- Cold or flu-like symptoms
- Headaches
- sweating
- insomnia
- Nausea
- Mood swings
- Pain
- restlessness
Like other opioids, Suboxone have been associated with respiratory depression (difficulty breathing) especially when combined with other depressants.
Cautions
Intravenous use of Suboxone usually in combination with benzodiazepines or other CNS depressants has been associated with significant respiratory depression and death. Suboxone has the potential for abuse and produces dependence of the opioid type with a milder withdrawal syndrome than full agonists. There are no adequate and well-controlled studies of Suboxone use in pregnancy. Due caution should be exercised when driving cars or operating machinery.
The two drugs, along with a dummy pill called a placebo, were tested for 22 months among 126 patients in Malaysia who had emerged from a detoxification and counselling programme, it said.
Buprenorphine, which is marketed as Temgesic or Buprenex, was twice as effective as naltrexone (branded as Revia, Depade or Vivitrol) and the placebo in terms of days of abstinence from heroin and a full-fledged relapse to the narcotic.
Indeed, buprenorphine proved to be so superior that the trial was halted early, as it would have been unethical to continue it to its scheduled end.
The study, led by Yale University’s Richard Schottenfeld, gives support for placing buprenorphine alongside methadone, and both of them over naltrexone, as pharmacological treatments for helping addicts stay off heroin.
The three drugs belong to a class called opioid antagonists.
These treatments are increasingly used to help ease heroin dependence but remain prohibited in some countries, amid suspicions that they are liable to be abused or simply substitute one addiction for another.
The study is important because it gives the first assessment of the relative effectiveness of two of the opioid antagonists.
Heroin and other illicit opiates were once a problem mainly confined to developed countries, but in the past few decades have spread to developing economies and nations of the former Soviet bloc.
China, India, Indonesia, Iran, Malaysia, Pakistan and Russia are among the countries where expansion of heroin use has risen fastest, according to a 2004 World Health Organisation (WHO) paper.
Deadly $2 Heroin Targets Teens Feb 06, 2008
DALLAS, Texas (CNN) — A cheap, highly addictive drug known as "cheese heroin" has killed 21 teenagers in the Dallas area over the past two years, and authorities say they are hoping they can stop the fad before it spreads across the nation.
"Cheese heroin" is a blend of so-called black tar Mexican heroin and crushed over-the-counter medications that contain the antihistamine diphenhydramine, found in products such as Tylenol PM, police say. The sedative effects of the heroin and the nighttime sleep aids make for a deadly brew.
"A double whammy — you’re getting two downers at once," says Dallas police detective Monty Moncibais. "If you take the body and you start slowing everything down, everything inside your body, eventually you’re going to slow down the heart until it stops and, when it stops, you’re dead." (Audio slide show: A father describes his teen son’s death)
Steve Robertson, a special agent with the Drug Enforcement Administration in Washington, says authorities are closely monitoring the use of "cheese" in Dallas.
Trying to keep the drug from spreading to other cities, the DEA is working with Dallas officials to raise public awareness about the problem. Authorities also are trying to identify the traffickers, Robertson says.
"We are concerned about any drug trend that is new because we want to stop it," he says.
Why should a parent outside Dallas care about what’s happening there?
Robertson says it’s simple: The ease of communication via the Internet and cell phones allows a drug trend to spread rapidly across the country.
"A parent in New York should be very concerned about a drug trend in Dallas, a drug trend in Kansas City, a drug trend anywhere throughout the United States," he says.
Middle schoolers acknowledge ‘cheese’
"Cheese" is not only dangerous. It’s cheap. About $2 for a single hit and as little as $10 per gram. The drug can be snorted with a straw or through a ballpoint pen, authorities say. It causes drowsiness and lethargy, as well as euphoria, excessive thirst and disorientation. That is, if the user survives.
Authorities aren’t exactly sure how the drug got its name "cheese." It’s most likely because the ground-up, tan substance looks like Parmesan cheese. The other theory is it’s shorthand for the Spanish word "chiva," which is street slang for heroin.
By using the name "cheese," drug dealers are marketing the low-grade heroin to a younger crowd — many of them middle schoolers — unaware of its potential dangers, authorities say.
"These are street dealers, dope dealers," Moncibais recently warned students at Sam Tasby Middle School. "They give you a lethal dose. What do they care?"
Moncibais then asked how many students knew a "cheese" user. Just about everyone in the auditorium raised a hand. At one point, when he mentioned that the United States has the highest rate of drug users in the world, the middle schoolers cheered. (Watch middle schoolers raise hands, admit they know drug users Video)
"You know, I know being No. 1 is important, but being the No. 1 dopeheads in the world, I don’t know whether [that] bears applause," Moncibais shot back.
Authorities say the number of arrests involving possession of "cheese" in the Dallas area this school year was 146, up from about 90 the year before. School is out for the summer, and authorities fear that the students, with more time on their hands, could turn to the drug.
‘Cheese’ as common a problem as pot
School officials and police have been holding assemblies, professional lectures, PTA meetings and classroom discussions to get the word out about the drug. A public service announcement made by Dallas students is airing on local TV, and a hotline number has been created for those seeking assistance.
Drug treatment centers in Dallas say teen "cheese" addicts are now as common as those seeking help for a marijuana addiction. "It is the first drug to have even come close in my experience here," says Michelle Hemm, director of Phoenix House in Dallas.
From September 2005 to September 2006, Phoenix House received 69 "cheese" referral calls from parents. Hemm says that in the last eight months alone, that number has nearly doubled to 136. The message from the parents is always, "My kid is using ‘cheese,’ " she says.
Phoenix House refers them to detoxification units first, but Hemm says at least 62 teens have received additional treatment at her facility since last September.
Fernando Cortez Sr. knows all too well how devastating cheese heroin can be. A reformed drug user who has spent time in prison, Cortez had spoken to his children about the pitfalls of drug use. He thought his 15-year-old son was on the right track.
But on March 31, his boy, Fernando "Nando" Cortez Jr., was found dead after using cheese heroin. "I should have had a better talk with him," he says. "All it takes is once. You get high once and you die, and that’s what happened to my son." He knows it’s too late for his son. Now, he is using his son’s story to help others. "All I can do is try to help people now. Help the kids, help the parents."
All About Heroin Jan 22, 2008
Dozens of opiates and related drugs (sometimes called opioids) have been extracted from the seeds of the opium poppy or synthesized in laboratories. The poppy seed contains morphine and codeine, among other drugs. Synthetic derivatives include hydrocodone (Vicodin), oxycodone (Percodan, OxyContin), hydromorphone (Dilaudid), and heroin (diacetylmorphine). Some synthetic opiates or opioids with a different chemical structure but similar effects on the body and brain are propoxyphene (Darvon), meperidine (Demerol), and methadone. Physicians use many of these drugs to treat pain.
Opiates suppress pain, reduce anxiety, and at sufficiently high doses produce euphoria. Most can be taken by mouth, smoked, or snorted, although addicts often prefer intravenous injection, which gives the strongest, quickest pleasure. The use of intravenous needles can lead to infectious disease, and an overdose, especially taken intravenously, often causes respiratory arrest and death.
Addicts take more than they intend, repeatedly try to cut down or stop, spend much time obtaining the drug and recovering from its effects, give up other pursuits for the sake of the drug, and continue to use it despite serious physical or psychological harm. Some cannot hold jobs and turn to crime to pay for illegal drugs. Heroin has long been the favorite of street addicts because it is several times more potent than morphine and reaches the brain especially fast, producing a euphoric rush when injected intravenously. But prescription opiate analgesics, especially oxycodone and hydrocodone, have also become a problem.
In anyone who takes opiates regularly for a long time, nerve receptors are likely to adapt and begin to resist the drug, causing the need for higher doses. The other side of this tolerance is a physical withdrawal reaction that occurs when the drug leaves the body and receptors must readapt to its absence. This physical dependence is not equivalent to addiction. Many patients who take an opiate for pain are physically dependent but not addicted: The drug is not harming them, and they do not crave it or go out of their way to obtain it.
Detoxification
For some addicts, the beginning of treatment is detoxification — controlled and medically supervised withdrawal from the drug. (By itself, this is not a solution, because most addicts will eventually resume taking the drug unless they get further help.) The withdrawal symptoms — agitation; anxiety; tremors; muscle aches; hot and cold flashes; sometimes nausea, vomiting, and diarrhea — are not life-threatening, but are extremely uncomfortable. The intensity of the reaction depends on the dose and speed of withdrawal. Short-acting opiates, like heroin, tend to produce more intense but briefer symptoms.
No single approach to detoxification is guaranteed to be best for all addicts. Many heroin addicts are switched to the synthetic opiate methadone, a longer-acting drug that can be taken orally or injected. Then the dose is gradually reduced over a period of about a week. The anti-hypertensive (blood pressure lowering) drug clonidine is sometimes added to shorten the withdrawal time and relieve physical symptoms.
Methadone Maintenance
Since the 1970s, professionals who care for opiate addicts have reluctantly recognized that many of them will not or cannot stop taking the drug. The solution is maintenance — dispensing opiates under medical supervision. More than 100,000 American addicts are now using methadone as a maintenance treatment. Although it is still politically controversial, this practice has better scientific support than any other treatment for any kind of drug or alcohol addiction.
Because there is a risk of diversion to the illicit market, addicts must come to specialized clinics for methadone, which they take daily in liquid form. A single dose lasts 24–36 hours, and there are few side effects. Some methadone clinics also provide other medical and social services.
Addicts who switch from illicit opiates to methadone avoid the highs and lows and the medical risks of intravenous injection and the criminal behavior that supports it. Studies show that they are less depressed, more likely to hold a job and maintain a family life, less likely to commit crimes, and less likely to contract HIV or hepatitis. Methadone can be continued indefinitely, or the dose can be gradually reduced in preparation for withdrawal. It has been estimated that about 25% of patients eventually become abstinent, 25% continue to take the drug, and 50% go on and off methadone repeatedly.
Buprenorphine
A promising approach to maintenance is the partial opioid agonist buprenorphine. This drug is taken three times a week as a tablet held under the tongue. It occupies opiate nerve receptors and produces a mild opiate-like effect. At higher doses, it continues to produce the same weak effect while displacing more potent drugs. In a person who is physically dependent on opiates, buprenorphine causes a withdrawal reaction. There is some risk of abuse if the tablet is dissolved and injected, so buprenorphine has been made available in combination with the short-acting opiate antagonist naloxone, which has little effect when absorbed under the tongue but neutralizes the effect of injected opiates.
The main advantage of this combination, sold under the name Suboxone, is that patients do not have to come to clinics to take it, because there is no illicit market and no danger of diversion. Since 2002, individual physicians with proper training and certification have been allowed to prescribe buprenorphine in their offices for patients to take home.