Opioid dependence is a chronic and relapsing medical disorder with a well-established neurobiological basis. Opioid agonist treatments, such as methadone and the recently approved buprenorphine, stabilize opioid receptors and the intracellular processes that lead to opioid withdrawal and craving. Both methadone and buprenorphine have been proven effective for the treatment of opioid dependence and can contribute to a decreased risk of human immunodeficiency virus (HIV) transmission. In addition, a buprenorphine/naloxone combination appears to have a decreased potential for abuse or diversion, compared with that associated with methadone. Largely because of these properties, recent legislation now affords an unprecedented opportunity for general physicians to offer opioid agonist treatment through their offices. This review focuses on the neurobiological basis of opioid dependence, the rationale for methadone and buprenorphine treatments, and issues in prescribing these medications to patients with HIV infection.
"Methadone and buprenorphine are full and partial muopioid receptor agonists, respectively, that are utilized as medications in the treatment of opioid dependence. Medication-assisted treatment (MAT) has been shown to be highly effective in reducing heroin and illicit prescription opioid use, promoting retention in treatment (Fiellin, Friedland, & Gourevitch, 2006; Mattick et al., 2008; Mattick, Breen, Kimber, & Davoli, 2009; O'Connor & Fiellin, 2000; Schwartz et al., 2006; Sees et al., 2000; Weiss et al., 2011), and reducing risk factors for the transmission of HIV and other blood-borne diseases (Gowing, Farrell, Bornemann, & Ali, 2008; Metzger et al., 1993). Despite the multiple positive outcomes demonstrated, the majority of opioid-dependent patients are not enrolled in MAT (Friedman et al., 2004; Stancliff, Myers, Steiner, & Drucker, 2002). "
[Show abstract][Hide abstract] ABSTRACT: Medication-assisted treatment for opioid dependence is safe and effective, yet negative perceptions about methadone and buprenorphine may discourage patients from entering treatment. One source of information that may influence viewers' perceptions is television. We performed a content analysis of a popular reality television program on addiction treatment. Although many patients had histories of opioid use, there were no positive messages about methadone or buprenorphine. The two main messages were that they (1) are primarily drugs of abuse, and (2) not acceptable treatment options. These messages reinforce negative stereotypes and may perpetuate stigma. There were multiple missed opportunities to provide evidence-based information.
"These results have been attributed to the similarities between the effects of d-amphetamine and those of cocaine and the usefulness of d-amphetamine to serve as a replacement drug in cocaine-dependent individuals (Grabowski et al. 2004b; Shearer 2008). This idea of agonist replacement therapy was first proposed for the treatment of opiate dependence (Dole et al. 1966; Kreek 2000), and is currently a primary line of treatment for heroin and prescription opiate dependence (e.g., methadone maintenance and levo-alphaacetyl-methadol treatment; Fiellin et al. 2006; Kreek and Vocci 2002) as well as tobacco smoking (i.e., nicotine replacement therapy; Fiore 2000; Stead et al. 2008). "
[Show abstract][Hide abstract] ABSTRACT: Recent studies have investigated D-amphetamine as a potential agonist medication for cocaine dependence. In rats, a 14-day continuous infusion of D: -amphetamine via osmotic mini-pump has been shown to decrease cocaine-reinforced responding under a progressive ratio (PR) schedule of reinforcement.
This study was designed to assess the influences of the D-amphetamine treatment dose and self-administered cocaine dose on the magnitude of this effect.
Experiment 1: rats were trained to self-administer 1.5 mg/kg/inj cocaine under a PR schedule, then implanted with D-amphetamine mini-pumps for 14 days (days 1-7, 5 mg/kg/day; days 8-14, 7.5 mg/kg/day). Breakpoints were evaluated throughout the treatment period and 14 days post-treatment. Experiment 2: rats were trained to self-administer cocaine under a PR schedule and initial dose-response curves were determined before implantation of D-amphetamine mini-pumps. During the 14-day D-amphetamine (5 mg/kg/day) treatment period, rats self-administered one of four cocaine doses (0.19, 0.38, 0.75, or 1.5 mg/kg/inj). A post-treatment PR dose-response curve and responding under a fixed ratio 1 (FR1) schedule were evaluated after mini-pump removal.
Experiment 1: breakpoints for 1.5 mg/kg/inj cocaine were unchanged by the increasing dose of D-amphetamine. Experiment 2: the PR dose-response curve was shifted downward after the treatment period in rats that had self-administered 0.19 and 0.38 mg/kg/inj cocaine. In contrast, rats in the 0.75 and 1.5 mg/kg/inj groups demonstrated increased rates of cocaine intake under an FR1 schedule after the treatment period.
These data suggest that continuous D-amphetamine treatment attenuates the reinforcing effects of cocaine.
[Show abstract][Hide abstract] ABSTRACT: Drug abuse and infection with human immunodeficiency virus (HIV) are associated with high rates of morbidity and mortality, but, because of medical, social, and legal factors, opiate addiction/dependence is a major obstacle to successful treatment of disease--for example, treatment of acquired immunodeficiency syndrome (AIDS) with highly active antiretroviral therapy. In an effort to improve the opportunity for treatment of drug abuse and HIV infection, the Forum for Collaborative HIV Research, in collaboration with the Substance Abuse and Mental Health Services Administration, the National Institute on Drug Abuse, the Centers for Disease Control and Prevention, and other agencies, presented a workshop entitled "Buprenorphine in the Primary HIV Care Setting." Participants reviewed and discussed current issues, such as the introduction of and sources for the provision of buprenorphine in HIV primary care settings and strategies for integrating treatment of HIV-infected drug abusers, all of which are covered in this supplement.
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