Professor Joanne Neale joins Rob Calder on the Addiction Audio podcast to talk about her latest research into how people feel during the first three days of taking Buvidal – a long-acting form of buprenorphine, prescribed for people dependent on opioids.

Jo’s research with Dr Stephen Parkin and Professor John Strang was published in Addiction in February 2023. Their article presented data from the first wave of a longitudinal study examining people’s experiences of long-acting buprenorphine, which is “administered subcutaneously and provide[s] sustained medication release…remov[ing] the need for daily attendance at services”. Participants were interviewed within 72 hours of starting Buvidal to glean some of the positive and negative short-term effects of this treatment.

In season two, episode four of Addiction Audio, Jo spoke to podcast host Rob Calder about the background to the research, why the concepts of ‘embodiment’ and ‘embodied cognition’ proved to be so useful for understanding people’s experiences, and some of the practical implications of the research for treatment delivery.

“Historically, we’ve had relatively limited treatment options for people who are dependent on opioids. The options are still relatively limited, to be honest. But in recent years, we’ve had the emergence of these long-acting formulations…you have them either in implantable form or in depot injection form, and then the medication is released slowly over a period of weeks or months rather than having to go for daily dosing.”

Rob notes that interest in long-acting buprenorphine has peaked in recent years and wonders whether this was related to the COVID-19 pandemic. Jo explains that one of the main benefits of this medication is that it removes the requirement for daily attendance at a pharmacy, which might have been advantageous during this time. However, she says the roll-out of long-acting buprenorphine and the perceived need for it “predated the pandemic”.

“It has many potential advantages to people, and one of those is it reduces the need for daily dosing. They don’t need to go to the pharmacy every day. They can just go to the clinic for an injection once a week or once a month, and that obviously has benefits in terms of freeing up time for them and reducing the stigma of having to go to the pharmacy. In countries where people have to pay for dispensing, it saves them some money. But that doesn’t mean to say it’s necessarily right for everybody. Because obviously there are people who probably don’t mind going to the pharmacy every day to get some contact and structure, and so there are pros and cons.”

Talking to people during the first 72 hours of treatment enabled the research team to capture how people felt “at the very start of their journey”. Long-acting medications for opioid use disorder are often framed as ‘game-changing’ treatments because of their potential to free people from daily check-ins and meetings with pharmacists and clinicians. But they may also come with their own anxieties, worries, or side effects, as well as other unexpected early benefits. Learning what initiation onto this medication feels like could, in theory, help prepare patients for starting (and sticking with) long-acting buprenorphine. What emerged from the study was a complex story of positive and negative psychological and physical experiences – sometimes at the same time and sometimes passing very quickly. Bodily experiences included withdrawal symptoms, poor sleep, and pain or soreness at the injection site, in addition to improved sleep, better skin, and increased appetite. Cognitive responses included anxiety, uncertainties, and depression, and in some cases, improved mood, greater positivity, and reduced cravings.

Rob asks Jo whether they were able to unpick which ‘symptoms’ or ‘side effects’ were a direct impact of treatment and which were related to other factors or life circumstances. Jo says that, understandably, it can be very difficult to disentangle these things, especially as withdrawal symptoms can manifest like so many ‘everyday problems’.

“Withdrawal symptoms are ubiquitous, you know. Is it a cold coming on? Is it COVID? Somebody said, ‘I’ve got aches and pains – is that my rheumatism playing up?’ And I think that’s part of trying to tease out…It’s quite helpful to know what the side effects are that you might experience so you can be prepared for them. But then sometimes you are gonna sit and scratch your head and wonder whether that side effect is the result of something else going on in your life. And for this particular group, there were just so many things that could be affecting what they were feeling.”

Jo then draws from the embodiment literature to explain how withdrawal can present and trigger someone to take corrective action to stabilise their body, in the same way that someone might take corrective action to cool down or reduce pain.

“When people use substances, they probably don’t think about the fact that that they’re not sleeping well, not eating well, that they’ve got constipation, that they’ve got a toothache. For many people, when they’re using opioids, a lot of that would be masked. But when they start to withdraw or come off the opioids, many of those feelings – and they can be physical feelings or emotional feelings, it can be taste, smell, wanting to cry, wanting to laugh – they kind of bubble back to the surface. In the ‘embodiment literature’ speak, we’re mostly not conscious of our body until there’s some kind of crisis, or something disturbs our equilibrium. Then when that crisis or equilibrium is disturbed, we find the need to do something to rectify it. So for example, if we find we’ve got a toothache, we might go and take some paracetamol. If we find we are too hot, we might wash our face in cold water or go outside into the cool air. And the same is applied in terms of substance use. When people start to come off substances, the body starts to function – kick in – do things they probably did before they were using opiates, and then they often will take corrective action to try to restabilise their bodies. So if they’re feeling withdrawal, they might take more substances, even without probably thinking about it, because subconsciously, they know that the substance is going to take away the pain of the withdrawal. So that’s the kind of feedback loop – the way that the mind and the body interact.”

Listen to the full episode of Addiction Audio for insight into why ‘game-changing’ longer-lasting medications may not be suited to everyone, and an interesting anecdote about how the comments of a peer reviewer changed the way the research team reported the findings.

Original article: How do patients feel during the first 72 h after initiating long-acting injectable buprenorphine? An embodied qualitative analysis. By Joanne Neale and colleagues. Published in Addiction (2023).

by Natalie Davies

Editor’s note: Quotes have been condensed and edited for clarity.

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