The clinical use of Buprenorphine-Naloxone in the opioid-dependent patient with Hepatitis C

Introduction: Guidelines for the treatment of opioid dependence which developed by organizations such as American Society of Interventional Pain Physicians (ASIPP) and the American Psychiatric Association (APA) recommend extensive treatment with pharmacological treatments such as methadone, buprenorphine, buprenorfine-naloxone as well as psychosocial therapy. Buprenorphine-Naloxone therapy is being used effectively as an alternative treatment to entering patients into a methadone outpatient clinics (1). The clinical relevant effect of buprenorphine depends on m-opioid receptor agonism (2).

Case: 16-years-old male patient with opioid dependence diagnosed according to DSM-IV criteria entered CEMATEM ( Child and Adolescent Alchol and Substance Treatment Centre ) clinic for out-patients in Bakirkoy Research and Training Hospital for Psychiatry and Neurology and a week later the patient has been hospitalized. Liver enzyme levels were normal and opiat value was found as positive in sub-threshold in routine controls and after 6- 8 hours Buprenorfin-Naloksan combination (Suboxone) treatment was received the patient experienced withdrawal symptoms.In patient's routine blood tests, hepatitis C virus (HCV) was determined and the patient developed significiantly elevated liver enzyme levels during buprenorphine-naloxone treatment.

Conclusions: Although Buprenorphine has been used clinically in the early 1970s, it's metobolism has not been fully unterstood already (3). Buprenorphine was mainly metobolized by N-dealkylation and glucuronidation of buprenorphine and norbuprenorphine by CYTP450 isoforms in liver ( 4). For non-hepatitis subjects, buprenorphine treatment showed no evidence of altered liver enzyme levels. In contrast, AST and ALT levels increased significantly with buprenorphine treatment among patients with a history of hepatitis (5). Liver enzym values significiantly elevated in this case with hepatitis C received Buprenorphine-Naloxone combination treatment. Bulletin of Clinical Psychopharmacology 2011;21(Suppl. 2):S201-2