Priorities and concerns of people who use opioids are key to scaling up XR-buprenorphine

Concise statement:

Larence et al.’s findings have key implications for XR-buprenorphine guidelines as it becomes available internationally. These are to embrace less-onerous dosing schedules, to consider incorporating into standard-of-care an option to supplement with transmucosal buprenorphine between injections, and to investigate what possibilities XR-buprenorphine opens up for patients wanting to taper off opioid agonist treatment.

Commentary:

Via interviews with 402 people in Australia who use opioids, Larance et al. identified perceptions and reservations about an extended-release (XR) buprenorphine injection as opioid agonist treatment (OAT) (1). Careful attention to prescribing guidelines that can facilitate scale-up are essential to bring XR- buprenorphine from promising idea to actual public health benefit. Most (68%) participants reported that XR-buprenorphine was a good treatment option for them, with no significant difference in support based on current or lifetime OAT. Learning from people who may potentially receive XR-buprenorphine about what they want from OAT can promote options to support various models of recovery. Conversely, de-emphasizing these patient perspectives is one way to end up with expensively-developed yet unused treatments. The early adoption of XR-buprenorphine in the United States provides an illustrative example.

In the United States, two XR-buprenorphine modalities (the depot injection and a subdermal implant) are approved by the Food and Drug Administration (FDA). In the U.S. Medicaid population, the largest U.S. payor for behavioral health treatment (including OUD), uptake of the injection has steadily increased since its approval in November 2017 (Figure 1). Conversely, utilization of the buprenorphine implant has remained vanishingly low since its FDA approval in May 2016 (2, 3). Though the numbers are well behind the more than 1 million prescriptions of short-acting buprenorphine with naloxone each quarter in the Medicaid setting, the steady increase indicates an opportunity to devote effort to improve uptake of the XR-buprenorphine injection. Coupled with findings from studies on patient perspectives, these utilization data suggest three unique opportunities for jurisdictions currently launching or scaling up XR-buprenorphine.

Figure 1.

Utilization of short- and long-acting buprenorphine to treat opioid use disorder in U.S. Medicaid, 2016–2019

Quarterly prescription counts for short-acting and long-acting buprenorphine paid for by U.S. Medicaid, 2016 – 2019. Cell counts under 11 were suppressed: values <30 represent upper bound of national prescriptions across all utilization types (i.e., fee-for-service, managed care organization).

1. Embrace flexibility to support scale-up

As the participants in Larance et al. reported, XR-buprenorphine offers an opportunity to decrease logistical burdens of OAT – the most commonly reported advantages were attending treatment services less frequently, having time to do other things, and opportunity to travel. Additionally, XR-buprenorphine stands to improve retention in treatment, which is a major challenge for daily OAT (4). Reducing barriers to accessing XR-buprenorphine, such as keeping cost on-par with or lower than daily OAT and not requiring people to “fail” a daily OAT first, can maintain flexibility in supporting life outside of treatment.

2. Accommodate dose adjustment

The most common concern reported in this study was that XR-buprenorphine will not sufficiently prevent withdrawal symptoms. Making transmucosal buprenorphine available between injections as standard of care can mitigate this concern.

How this will be operationalized will likely vary by patient and by setting. One option would be to dispense a small amount of transmucosal buprenorphine at the same time as the injection for as-needed dose adjustment; another would be to provide a prescription that could be filled later if needed. In situations where tampering or diversion is a significant concern, limiting the quantity of between-injections transmucosal buprenorphine may be warranted. In the initial days and weeks of starting XR-buprenorphine, providing opportunities for rapid in-person follow-up can promote patient autonomy while reducing opportunities to divert the supplemental buprenorphine. Though such “rescue dosing” has necessarily been absent from double-blind placebo-controlled trials (5), it would be useful for comparative effectiveness studies and pragmatic trials to include supplemental daily-buprenorphine in their protocols. Until best practices are established through research, guidelines offering supplemental transmucosal buprenorphine can further support autonomy for patients receiving OAT.

3. Investigate unique contributions of long-acting buprenorphine

This study also highlights the opportunity to explore whether XR-buprenorphine injections can act as a gradual taper for people who want to eventually stop taking buprenorphine. This may be particularly relevant to those in the 1–2 year current treatment episode group who were most likely to endorse XR-buprenorphine in this study. The possibility of an easier taper may also facilitate willingness to enter treatment for people who are open to OAT but concerned about the difficulty of weaning off OAT once started.

Injectable XR-buprenorphine provides an interesting and important opportunity to add to the portfolio of tools for managing opioid use disorder. Guidelines that center patient viewpoints may well be key to making it a success story.