Abstract
Description
This article discusses how monthly extended-release buprenorphine can be used to improve the treatment of opioid use disorder (OUD). In particular, the use of monthly extended-release buprenorphine holds promise for patients who have recently been released from jail or prison and are battling OUD, those who are unstable and continue to use opioids illicitly, patients who are experiencing homelessness while also struggling with OUD, and those who are stable and want to be weaned off buprenorphine.
Keywords: buprenorphine, opiate substitution treatment, opioid-related disorders, opioid use disorder, OUD, narcotic antagonists, vulnerable populations
Introduction
Monthly extended-release buprenorphine (Sublocade, Indivior, North Chesterfield, Virginia; Brixadi; Braeburn, Plymouth Meeting, Pennsylvania; other brands under United States Food and Drug Administration review) is an injectable extended-release buprenorphine that represents an advance in the treatment of opioid use disorder (OUD).1,2 The challenges often faced with both patient access to medications for opioid use disorder (MOUD) and adherence to treatment could be addressed by the extended-release injection of buprenorphine. Monthly injectable buprenorphine may be appropriate for specific categories of patients, including those who have been recently released from jail and are battling OUD,1,3,4 patients who are unstable on sublingual formulations and continue to use opioids illicitly, those experiencing homelessness while also struggling with OUD, and patients who are stable and want to be weaned off buprenorphine.4
Populations That Could Benefit From Monthly Long-Acting Buprenorphine
Patients released from jail or prison
Patients with OUD who have been released from jail experience a 40-fold increased risk of death in the first month after leaving jail.5 With the newly available once-monthly extended-release buprenorphine, it is possible to administer injectable buprenorphine to incarcerated people at the time of release. They would likely benefit from buprenorphine’s protection against both opiate withdrawal and overdose for the following month.1,6 Stabilizing a patient for the first 30 days after leaving jail is vital to reduce the risk of overdose and death during this interval.6 Patients may not be able to immediately find a MOUD provider and often have gaps in insurance coverage following incarceration. Giving patients a single dose at the time of release provides them with a full month to get established with a provider and resolve any payor issues. Currently, there are few jails providing buprenorphine; those that do prescribe it provide patients with only a few days’ supply of the sublingual buprenorphine when they are released.3,6,7 Therefore, patients are being released with only a 1–2 days’ supply of buprenorphine before going into withdrawal. The addiction medicine community has a responsibility to work with the criminal justice system to improve this situation to benefit our patients.3,6
Patients who are unstable and continue to use opioids illicitly
A second category of patients who could benefit from monthly extended-release buprenorphine are those who are unstable and still engaging in care but continue to test positive for both illicit opioids and buprenorphine on a urine drug screen (UDS). In these cases, we would be concerned that the patient may be missing doses of their sublingual buprenorphine because they are taking illicit opioids or because they sold all or some of their buprenorphine instead of taking it themselves.1 Monthly, long-acting, subcutaneous buprenorphine administered by the provider eliminates the chance of missing daily doses or using the sublingual medication inappropriately once dispensed. The plasma concentrations of buprenorphine on high-dose extended-release subcutaneous buprenorphine are higher than the maximum dose of sublingual buprenorphine, making it more likely to help patients to refrain from continued illicit use while continuing to provide protection from overdose.8,9 Patients receiving extended-release subcutaneous buprenorphine are expected to greatly reduce illicit opioid use because they cannot divert the buprenorphine once it has been injected. It is often easier to ensure the patient adheres to their monthly dose administered by medical staff instead of a self-administered daily dose–similar to adherence benefits documented with long-acting injectable antipsychotics.10,11 According to a qualitative study by Velasquez et al, patients who tried opioids again while on extended-release buprenorphine generally stated that they did not feel pleasure from opioid use, encouraging them to stay off opioids.6 If a provider is worried about diversion or adherence to buprenorphine, then monthly extended-release buprenorphine would reduce these concerns.3
Patients experiencing homelessness
When patients who are experiencing homelessness and have OUD are prescribed standard formulations of buprenorphine, it is a struggle to keep a supply of buprenorphine available to them. Patients experiencing homelessness often do not have a safe place to store their buprenorphine and may lose it or have their medications stolen during the course of treatment. If they find themselves without a supply of sublingual buprenorphine, they begin to experience withdrawal symptoms and are at risk of returning to illicit drug use to ameliorate these withdrawal symptoms.
A once-monthly formulation of buprenorphine would prevent this problem as patients would not have to store or protect their buprenorphine daily tablets or films. The once-monthly extended-release buprenorphine limits the risk of lost or stolen medication, and the patient only needs to access their provider once a month, which reduces the need for transportation since going to a daily, or even weekly, dosing clinic is difficult.6
Patients who are stable and want to be weaned off buprenorphine
Finally, the duration of buprenorphine treatment and the difficulty of weaning off without withdrawal or return to use are of great concern to OUD patients and prescribers. Patients who have been stable on buprenorphine long-term have anecdotally stated that weaning off buprenorphine has been easier with the extended-release injectable than with the daily dosing. At our addiction clinic, we have had patients who have tried to wean off the daily dosing of buprenorphine and have had difficulty due to cravings and withdrawal symptoms. We have offered the extended-release once-monthly injection of buprenorphine for up to 3 doses prior to complete cessation. The long half-life of the depot form allowed for a very smooth transition off of buprenorphine for these patients, and their UDS was negative for all opioids, including buprenorphine. More research is needed, but based on our clinical experience, switching to monthly extended-release buprenorphine has proven to be a good way to wean people when they choose to stop buprenorphine.
Discussion
Given the great potential benefit of monthly extended-release injectable buprenorphine, why are more providers not prescribing it? It is relatively new, and many providers are not aware of its benefits. Barriers include the cost of the medication for patients who do not have health insurance as well as the challenges of implementing a system for supplying the medication at the clinic.2,12 At the time of this writing, the medication costs $1576 per month for patients without insurance coverage per the GoodRx website.13 This referenced cost was for the brand-name Sublocade monthly injectable buprenorphine prior to the competitor Brixadi coming on the market; this competition may drive down the price and make the medication more affordable, especially for uninsured people. As described in our previous work, there are many barriers to implementing an efficient system to obtain the medication and have it available when needed.12 Dispensing can be handled by obtaining the medication directly from the distributor (buy and bill) or from a specialty pharmacy.12 The buy and bill option requires certification with the Risk Evaluation and Mitigation Strategy program. Therefore, despite some challenges, using a specialty pharmacy is usually more convenient for primary care providers.12
Although there are barriers of cost and procurement, we have identified 4 high-risk patient groups that extended-release buprenorphine could potentially help. More research is needed to determine how best to expand access to extended-release buprenorphine to benefit these and other high-risk patient populations.
Footnotes
Conflicts of Interest: The authors declare they have no conflicts of interest.
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