Buprenorphine chemical structure
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Buprenorphine

Buprenorphine, also colloquially referred to as bupe, is an opioid drug with partial agonist and antagonist actions. Buprenorphine hydrochloride was first marketed in the 1980s by Reckitt & Colman (now Reckitt Benckiser) as an analgesic, yet is now primarily used for the treatment of opioid addiction. It is a Schedule III drug under the Convention on Psychotropic Substances. more...

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Commercial preparations

Britsh firm Reckitt & Colman (now Reckitt Benckiser) first marketed buprenorphine under the trade names Temgesic (sublingual/parenteral preparations, no active additives) and Buprenex (parenteral, no active additives). Two more recent formulations from Reckitt Benckiser have been approved for opioid addiction treatment in the U.S.: Subutex (lemon-lime flavored sublingual, no active additives; in 2mg and 8mg dosages) and Suboxone (orange-tang flavored sublingual, one part naloxone for every four parts buprenorphine; hexagon shaped tablet in 2mg and 8mg dosages). Suboxone contains the opioid antagonist naloxone to deter illicit intravenous preparation of the tablet, this is intended to attenuate the effects of buprenorphine on opioid-naive users should this formulation be injected - however no human studies have been done demonstrating the efficacy of this approach with buprenorphine and a growing number of street reports indicate that the naloxone is ineffective. It must also be noted that buprenorphine in and of itself will induce a precipitated withdrawal syndrome if ingested by an acutely opioid dependent individual via any route.

Buprenorphine is also delivered transdermally in 25, 50 and 75 mcg/hour. The trade name in the UK is Transtec, and manufactured by Napp. A new 5, 10 and 20 mcg/hour patch marketed as Bu'7rans (Bu-trans), where the 7 indicates its once weekly dosage for pain in osteoarthritis.

Pharmacology and pharmacokinetics

Buprenorphine is a thebaine derivative, and its analgesic effect is due to partial agonist activity at μ-opioid receptors. The partial agonist activity means that opioid receptor antagonists (e.g. naloxone) only partially reverse the effects of buprenorphine. Buprenorphine is also a κ-opioid receptor partial agonist/antagonist, and partial/full agonist at the recombinant human ORL1 nociceptin receptor. (Huang et al., 2001)

Buprenorphine hydrochloride is administered by intramuscular injection, intravenous infusion, via a transdermal patch, or as a sublingual tablet. It is not administered orally, due to very high first-pass metabolism. Buprenorphine is metabolised by the liver, via the CYP3A4 isozyme of the cytochrome p450 enzyme system, into norbuprenorphine (by N-dealkylation) and other metabolites. The metabolites are further conjugated with glucuronic acid and eliminated mainly through excretion into the bile. The elimination half-life of buprenorphine is 20.4–72.9 hours (mean 34.6).

The main active metabolite, norbuprenorphine, is a δ-opioid receptor and ORL1 receptor agonist, μ- and κ-opioid receptor partial agonist. (Huang et al., 2001)

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Buprenorphine for pain relief in a patient with drug abuse
From American Journal of Drug and Alcohol Abuse, 12/1/91 by John R. Hughes

INTRODUCTION

The incidence of abuse of opioid analgesics can be substantial in patients with a present or past history of drug abuse [1]. Thus, physicians are often reluctant to prescribe opioid analgesics ad-libitum to patients with a history of drug abuse. On the other hand, physicians are reluctant to deny analgesia to any patient in true severe pain.

Buprenorphine, a mixed agonist/antagonist, differs from most opioid analgesics in several ways that may favor its use in patients with drug abuse histories. Compared to typical [mu]-agonist opioids, buprenorphine appears to produce less physical dependence [2-5], abuse liability [2,3], and respiratory depression [3]. In addition, buprenorphine blocks the euphoric effects of [mu]-agonist [6] and has a longer duration of analgesia (6-8 h), thus requiring infrequent self-administration [3]. On problem in using buprenorphine is that it can precipitate withdrawal from [mu]-agonist opioids [7]. It appears that buprenorphine can be administered soon after opioid use, but this is still somewhat unclear [8].

In this case study we illustrate the advantage of buprenorphine and report the absence of precipitated withdrawal or loss of analgesia when buprenorphine is given after omission of a single dose of morphine in a patient chronically maintained on morphine.

CASE REPORT

The patient was a 35-year old man with severe Crohn's disease which has required multiple surgeries and total parental nutrition for 7 years. The patient had a past and recent history of abuse of alcohol, sedatives, and opioids.

When we first saw the patient, he was receiving morphine sulfate (MS) 3.6 mg IV q 2 h. We first assessed whether the patient was physically dependent on opioids. If he was not dependent, then he could immediately be switched to buprenorphine. The patient consented to a single-blind naloxone challenge test which is typically used to assess physical dependence [8]. Injections of saline, then 0.2 mg and 0.6 mg naloxone were given IV. With 0.6 mg of naloxone, lacrimation, rhinorrhea, perspiration, piloerection, yawning, and restlessness were observed.

At this point the patient agreed to a single-blind attempt to switch him to buprenorphine. The patient's physician had decreased his morphine to 9 mg IV q 6 h. A 3-day baseline period then occurred in which 9 mg morphine was administered IV at 0300, 0900, 1500, and 2100. Each morning of this period, heart rate, respiratory rate, sitting blood pressure, and temperature were taken and the signs of opioid withdrawal [9] were rated. The patient also completed visual-analogue scales of pain, strength of medication, and good and bad effects, as well as a 20-item opioid withdrawal scale [7]. During this baseline the patient's vital signs and self-ratings were stable, plus observer and self-reported ratings of withdrawal were minimal (Fig. 1).

Next we substituted saline for his 0300 dose of MS. The next morning his vital signs, observer signs of withdrawal, and self-ratings of withdrawal and pain were unchanged. We then began buprenorphine 0.6 mg IV 6 h. Measures at 0.5 h after this first dose showed a possible slight increase in observer and self-rated withdrawal. Repeat measures immediately before and 0.5 h after the next dose of buprenorphine and aily thereafter showed no indication of precipitated withdrawal or increased pain. Analgesia was not interrupted with this protocol.

DISCUSSION

Buprenorphine was used in this patient for two reasons. First, the patient had a history of drug dependence. Buprenorphine appears to produce less physical dependence [1-5] than typical [mu]-agonist opioid analgesics. Second, the patient had a history of impulsive behavior and intoxication. Buprenorphone produces less respiratory depression than typical [mu]-agonist [3]. In the past, certain opioids have been suggested to have less dependence potential and abuse liability tahn [mu]-agonist (e.g., pentazocine). However, these opioids require cessation of [mu]-analgesics for 24-48 h, appear to produce more respiratory depression than buprenorphine, and, unlike buprenorphine, appear to be less acceptable analgesics due to their psychotomimetic effects [8].

Several regimens have been used to transfer daily heroin users into buprenorphine (see Johnston et al. for a review) [8]. The duration between last use of a [mu]-opioid and administration of buprenorphine with these regimens has not been well-specified, but appears to be in the rnage of 12 to 24 h. In the present study we induced 12 h of abstinence by simply omitting the evenign dose of a q 6 h schedule. This protocol allowed us to transfer a patient to buprenorphine without precipitating withdrawal and, importantly, without interrupting analgesia.

References

[1] Portenoy, R. K., and Foley, K. M., Chronic use of opioid analgecis in non-malignant pain: Report of 38 cases, Pain 25:171-186 (1978).

[2] Jasinski, D. R. Pevnick, J. S., and Griffith, J. D., Human pharmacology and abuse potential of the analgesic buprenorphine, Arch. Gen. Psychiatry 35:601-616 (1978).

[3] Lewis, J., Rance, M. J., and Sanger, D. J., The pharmacology and abuse potential of buprenorphine, a new antagonist analgesic, in Advances in Substance Abuse, Behavioral and Biological Research, Vol. 3 (N. K. Mello, ed.), JAI Press, Greenwich, Connecticut, 1982.

[4] Lukas, S. E., Jasinski, D. R., and Johnson, R. E., Electroencephalographic and behavioral correlates of buprenorphine and administration, Clin. Pharmacol. Ther. 36:127-132 (1984).

[5] Mello, N. K., Mendelson, J. H., and Kuehnle, J. C., Buprenorphine's effects on human heroin self-administration, an operant analysis, J. Pharmacol. Exp. Ther. 36:127-132 (1984).

[6] Bickel, W. K., Stitzer, M. L., Bigelow, G. E., Liebson, I. A., Jasinski, D. R., and Johnson, R. E., Buprenorphine: Dose-related blockade of opioid challenge effects in opioid dependent humans, J. Pharmacol. Exp. Tehr. 247:47-53 (1988).

[7] Aceto, M. D., Characterization of prototypical opioid antagonists agonists/antagonist, and agonists in the morphine dependent rhesus monkey, Neuropeptides 5:15-18 (1984).

[8] Johnson, R. E., Cone, E. J., Henningfield, J. E., and Fudals, P. J., Use of buprenorphine in the treatment of opiate addiction. I. Physiologic and behavioral effects during a rapid dose induction, Clin. Pharmacol. Ther. 46:335-343 (1989).

[9] Jaffe, J. H., and Martin, W. R., Opioid analgesics and antagonists, in The Pharmacological Basis of Therapeutics (A. S. Gilman, L. S. Goodman, T. W. Rall, and F. Murad, eds.), Macmillan, New York, 1985.

COPYRIGHT 1991 Taylor & Francis Ltd.
COPYRIGHT 2004 Gale Group

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