Thomas R. Kosten

Buprenorphine for Office-based Practice: Consensus Conference Overview

This overview of the March 2003 conference on the U.S. national buprenorphine implementation program is developed to inform the practitioner about the positive experience that has been accumulated worldwide on the use of buprenorphine for office-based practice. The first paper delineates the challenges for American psychiatry in moving buprenorphine forward into general practice. Most psychiatrists are unprepared to work with opiate-dependent patients or to use buprenorphine. The international successes with office-based buprenorphine from France and Australia are presented in the next papers, followed by presentations on several U.S. studies using buprenorphine in the community for detoxification and office-based maintenance. These experiences have thus far confirmed buprenorphines utility and promise for opiate addiction treatment in the U.S. Finally, two national monitoring programs have been implemented to assess the public health impact of this new treatment opportunity. This opportunity has a three-year window, however, and a critical need will be to attract a sufficient number of physicians into prescribing buprenorphine/naloxone in order to allow our patients increased access to this treatment.

Isradipine Enhancement of Cerebral Blood Flow in Abstinent Cocaine Abusers with and without Chronic Perfusion Deficits

Nine cocaine abusers with cerebral blood flow (CBF) deficits (hypo-perfused areas) on HMPAO SPECT scans were compared to six without these deficits after six doses of isradipine (5 mg TID). When comparing the scan before isradipine to that after using SPM analysis, the ratio of hypo- to hyper-fusion showed a 16% increase in the maximum Z scores and 30% fewer areas of hypo-perfusion among those cocaine abusers with deficits. These deficits may represent segmental cerebral vasospasm that was reversed by this vasodilating agent in cocaine abusers with areas of hypo-perfusion (deficits) as baseline.

Interactions of cocaine with nimodipine: a brief report.

This double blind, placebo controlled study of acute calcium channel antagonist use during cocaine administration in five patients found that 60 mg of nimodipine treatment attenuated the systolic, but not diastolic, blood pressure effects of cocaine. In three subjects, a 90 mg dose of nimodipine showed a greater attenuation than that of 60 mg. Subjective effects of cocaine were not altered by either dose of nimodipine.

High‐ and low‐dose Mazindol for cocaine dependence in methadone‐maintained patients: A preliminary evaluation

We conducted a preliminary investigation comparing high‐dose mazindol (8 mg/day), low dose mazindol (1 mg/day), and placebo for cocaine abstinence initiation in a 12‐week, double‐blind, randomized clinical trial enrolling 17 cocaine‐dependent, methadone‐maintained patients. Outcome data did not support a difference between the two dose levels on percentage positive urine screens positive for cocaine (1 mg mazindol=68%, 8 mg mazindol=75%, placebo=91%). Doses of mazindol greater than 8 mg may be needed for a cocaine blocking effect, although potential pressor effects may be a limiting factor.