Cancer Treatment Today » Addiction Medicine

Subutex and Suboxone for Addiction – pro

M Levin, MD — Fri, 10 Aug 2012 00:39:43 +0000

Buprenorphin comes in a sublingual and transdermal formulation. In October 2002, the Food and Drug Administration (FDA) approved buprenorphine monotherapy product, Subutex®, and a buprenorphine/naloxone combination product, Suboxone®, for use in opioid addiction treatment. The combination product is designed to decrease the potential for abuse by injection.

The transdermal form is well-established for treatment of chronic cancer pain and. It was recommended for addiction purpose by a consensus conference(Pergolizzin et al). The sublingual form is much less studied in this setting. Notably, it was studied as long ago as 1979 by Robbie. He concluded that this sublingual preparation seems worthy of addition to the commercially available range of analgesics in clinical practice. Other publications appeared occasionally over the next 20 years and have been generally supportive. in 2005, Malinoff found it to be well tolerated and safe and appeared to be effective in the treatment of chronic pain patients refractory to other pain medications. It continued to be mildly recommended in more recent reviews.

Pergolizzi JV Jr, Mercadante S, Echaburu AV, Van den Eynden B, Fragoso RM, Mordarski S, Lybaert W, Beniak J, Orońska A, Slama O; Euromed Communications meeting.Curr Med Res Opin. 2009 Jun;25(6):1517-28.

D. S. Robbie A trial of sublingual buprenorphine in cancer pain. Br J Clin Pharmacol. 1979; 7(Suppl 3): 315S–317S.

Hotz G. Oral and maxillofacial cancer pain therapy with sublingual buprenorphine.Schmerz. 1988 Mar;2(1):38-41.

Malinoff HL, Barkin RL, Wilson G. Sublingual buprenorphine is effective in the treatment of chronic pain syndrome.Am J Ther. 2005 Sep-Oct;12(5):379-84.

Yokell MA, Zaller ND, Green TC, Rich JD. Buprenorphine and buprenorphine/naloxone diversion, misuse, and illicit use: an international review.Curr Drug Abuse Rev. 2011 Mar 1;4(1):28-41.

Opioids and the management of chronic severe pain in the elderly: consensus statement of an International Expert Panel with focus on the six clinically most often used World Health Organization Step III opioids (buprenorphine, fentanyl, hydromorphone, methadone, morphine, oxycodone). Pain Pract. 2008 Jul-Aug;8(4):287-313.

Pergolizzi J, Böger RH, Budd K, Dahan A, Erdine S, Hans G, Kress HG, Langford R, Likar R, Raffa RB, Sacerdote P. The role of transdermal buprenorphine in the treatment of cancer pain: an expert panel consensus.Pain Pract. 2008 Jul-Aug;8(4):287-313.

Read the Layperson version here.

Antabuse – pro

M Levin, MD — Sun, 05 Aug 2012 15:03:40 +0000

Antabuse, or disulfiram is approved for the treatment of alcohol abuse and alcohol dependence by the U.S. Food and Drug Administration. When alcohol is consumed it is metabolized by the body into acetaldehyde, and then into acetic acid, which is harmless. Antabuse interferes with this step, causing a buildup of acetaldehyde As a result, there is a build up of acetaldehyde five or 10 times greater than normally occurs when someone drinks alcohol. This causes unpleasant side effects and discourages alcohol use. FDA indication is: “in the management of selected chronic alcohol patients who want to remain in a state of enforced sobriety so that supportive and psychotherapeutic treatment may be applied to best advantage. Disulfiram is not a cure for alcoholism. When used alone, without proper motivation and supportive therapy, it is unlikely that it will have any substantive effect on the drinking pattern of the chronic alcoholic.”

It is not universally effective because it is a sufficiently short acting that one can stop it and return to alcohol use in a few days. There is a high rate of noncompliance and recidivism(returning to drinking) According to the U.S. Substance Abuse and Mental Health Services Administration, Antabuse (disulfiram) is more appropriate for older, motivated individuals and in those who are supervised during daily ingestion. Predictors of efficacy with disulfiram include patients highly motivated for abstinence, people who are married or have a good support system, people with behavioral contracts to take the medication, and people legally compelled to take disulfiram.”

Read the Layperson version here.

Inpatient Versus Outpatient Alcohol Rehab – pro

M Levin, MD — Sun, 05 Aug 2012 13:50:33 +0000

There are many similarities between inpatient and outpatient alcohol rehab programs. Both types of treatment programs provide direction and guidance to the patients and their families to educate them about what alcoholism is and how to set and meet appropriate goals for treatment and recovery. Inpatient therapy involves a 24/7 stay in a residential treatment facility that is isolated from the outside world. The goal is to provide a setting that keeps distractions and temptations to a minimum and allows the patient to focus on recovery. These types of treatment programs can be as short as four to six weeks or as long as several months to a year, depending on the severity of the addiction. Inpatient alcohol rehab is beneficial for those who are severely addicted or who have had trouble succeeding in other treatment settings in the past.

Outpatient alcohol rehab is generally suggested for those who aren’t heavily addicted to alcohol but still need help breaking their addiction to this drug. Treatment usually involves one or more meetings per week that can last from one to several hours and include behavioral therapy, group therapy and single therapy sessions, as well as educational classes and other treatments.

Outpatient treatment allows individuals to continue working, going to school and – in general – continuing their normal life. Inpatient treatment is much more costly than outpatient treatment. Inpatient therapy has the advantage of being an environment free from distractions and temptations, whereas outpatient therapy will allow one to be exposed to temptations that may lead to relapse. Inpatient therapy also allows one to recover physically going back to the ‘real world.’

American Academy of Child and Adolescent Psychiatry, Practice Parameter for the Assessment and Treatment of Children and Adolescents with Substance Use Disorders, 2007, http://www.aacap.org/galleries/PracticeParameters/JAACAP%20Substance%20use%202005.pdf

American Psychiatric Association, Practice Guideline for the Treatment of Patients with Substance Use Disorders, Guideline Watch 2007, http://www.psychiatryonline.com/pracGuide/PracticePDFs/SUDwatch041307.pdf

Clinical Practice Guideline, Management of Substance Use Disorders, VA/DoD Evidenced Based Practice, 2009, http://www.healthquality.va.gov/sud/sud_full_601f.pdf

Read the Layperson version here.

Pegasys for P. Vera and Essential Thrombosis – pro

M Levin, MD — Sat, 30 Jun 2012 17:24:02 +0000

Intron A is a well established treatment for essential thrombocythemia (ET) and P. Vera, especially effective for control of pruritis. Interferon-(IFN) suppresses growth of multipotent hematopoietic progenitor cells. No leukemogenic risk has been reported. No randomized trials have been published. In the Italian guidelines for treatment of ET 15 studies have been summarized, including 292 patients. Complete normalization of platelet counts was achieved in 54% of the patients.

Pegasys is a form of pegulated interferonPegylated IFN given weekly has been shown to have equal efficacy as IFN given trice weekly. The most recent guideline (Nordic MPD Study Group) recommendation is: ” Recommendation: IFN-α is theoretically superior for treating PV as it is effective in controlling proliferation of all cell lineages and there is no risk of leukemogenesis. Molecular remissions can be
acheived with IFN. It is most likely to be tolerated in patients below 60 years for whom it is
recommended. Pegylated forms of IFN seem equally effective as conventional IFN.
Grade B recommendation, evidence level III.

In summary, recent data suggest that pegylated INF alfa-2a (Pegasys; Hoffman-La Roche, Inc, Nutley, NJ) is likely to be as effective as IFN.
Barosi G, Lupo L, Rosti V. Management of myeloproliferative neoplasms: from academic guidelines to clinical practice.Curr Hematol Malig Rep. 2012 Mar;7(1):50-6.

McMullin MF, Bareford D, Campbell P, et al.: Guidelines for the diagnosis, investigation and management of polycythaemia/erythrocytosis. Br J Haematol 130 (2): 174-95, 2005.

Campbell PJ, Green AR: The myeloproliferative disorders. N Engl J Med 355 (23): 2452-66, 2006.
Finazzi G, Barbui T: How I treat patients with polycythemia vera. Blood 109 (12): 5104-11, 2007.

Kiladjian JJ, Cassinat B, Chevret S, et al.: Pegylated interferon-alfa-2a induces complete hematologic and molecular responses with low toxicity in polycythemia vera. Blood 112 (8): 3065-72, 2008

Cortes, MD, Deborah Thomas, MD, Guillermo Garcia-Manero, MD, Alessandra Ferrajoli, MD, Stefan Faderl, MD, Mary Ann Richie, Miloslav Beran, MD, PhD, DVM, Francis Giles, MD, Srdan Verstovsek, MD, PhD Final Result of a Phase 2 Study PEG-IFN–2b therapy in BCR-ABL-negative myeloproliferative disorders Cancer Volume 110 Issue 9, Pages 2012 – 2018

http://www.sfhem.se/filarkiv/files/vardprogram/NMPDGuidelines2007.pdf

and

http://www.hematology.dk/download.php?137ce10569b47edb9f4347782879fa97

Samuelsson J, Mutschler M, Birgegård G, Gram-Hansen P, Björkholm M, Pahl HL Limited effects on JAK2 mutational status after pegylated interferon alpha-2b therapy in polycythemia vera and essential thrombocythemia. Haematologica. 2006 Sep;91(9):1281-2.

ASCO 2011, 461 High Rates of Molecular Response After Long-Term Follow-up of Patients with Advanced Essential Thrombocythemia (ET) or Polycythemia Vera (PV) Treated with Pegylated Interferon-ALFA-2A (PEG-IFN-α-2A; PEGASYS )

Alcohol rehab and withdrawal – length of stay – pro

M Levin, MD — Sat, 23 Jun 2012 01:53:42 +0000

Rehabilitation for alcohol and other drugs has proliferated and differentiated into many different clinical approaches during the last 40 years. After acute emdical care for detox, when necessary, as in this case, according to the duration, the amount of alcohol and other drugs taken and type of drugs abused, a person might either need a social detox or a medical detox. Social detox may not be anything more than confined bed rest and someone to take vital signs to make sure that more intense care isn’t needed. Nonetheless, certain social detox facilities provide mega-vitamin therapy, massages, healthy nutrition and other holistic approaches that reduce the level of anxiety and discomfort of the patient. This is to assist in getting the individual to be more agreeable to continue his clinical care after detox. Medical treatment for withdrawal has the mean length of stay of 9.8 days . In one older observational study of 539 episodes of alcohol withdrawal in a general hospital, to determine the natural history, the incidences of seizures, hallucinations and delirium, and the risk factors for these events. The reaction began soon after arrival, at a median time of 5 h, and resolved at a median time of 22 h. Patients with a blood alcohol level of zero were in withdrawal on arrival, and only four patients had reactions lasting 120 h or longer. Complications were observed in 113 patients (21%) during the admission. Seizures occurred on arrival, hallucinations usually in the first 24 h and delirium in the first 48 h. No mortality was associated with alcohol withdrawal itself, but complications did extend length of stay by a median of 4 days, with delirium contributing most to the increase.

Suboxone, a Sublingual Preparation of Buprenorphine in Treatment of Chronic Cancer Pain – pro

M Levin, MD — Tue, 19 Jun 2012 21:14:52 +0000

The transdermal form is well-established for treatment of chronic cancer pain and. It was recommended for this purpose by a consensus conference(Pergolizzin et al). The sublingual form is much less studied in this setting. Notably, it was started as longer go us 1979 by Robbie. He concluded that this sublingual preparation seems worthy of addition to the commercially available range of analgesics in clinical practice. Other publications appeared occasionally over the next 20 years and have been generally supportive. in 2005, Malinoff found it to be well tolerated and safe and appeared to be effective in the treatment of chronic pain patients refractory to other pain medications. It continued to be mildly recommended in more recent reviews.

D. S. Robbie A trial of sublingual buprenorphine in cancer pain. Br J Clin Pharmacol. 1979; 7(Suppl 3): 315S–317S.

Hotz G. Oral and maxillofacial cancer pain therapy with sublingual buprenorphine.Schmerz. 1988 Mar;2(1):38-41.

Malinoff HL, Barkin RL, Wilson G. Sublingual buprenorphine is effective in the treatment of chronic pain syndrome.Am J Ther. 2005 Sep-Oct;12(5):379-84.

Yokell MA, Zaller ND, Green TC, Rich JD. Buprenorphine and buprenorphine/naloxone diversion, misuse, and illicit use: an international review.Curr Drug Abuse Rev. 2011 Mar 1;4(1):28-41.