Prolonged release buprenorphine has been bought into focus during the COVID-19 pandemic. It’s like usual buprenorphine but you only have to have a monthly, or weekly, injection rather than a daily sublingual (under the tongue) dose.
COVID-19 bought a spotlight on this because people who were self-isolating, or who were vulnerable could still receive opioid substitution therapy (OST – e.g. methadone, buprenorphine, heroin assisted treatment) without having to go to the pharmacist every day.
Key Points:
- Prolonged release buprenorphine can give some people a greater feeling of freedom and independence compared with daily forms of OST
- Prolonged release buprenorphine is not suitable for everyone, this research suggests that it might be more suitable for people who are stable in their recovery
- Although relatively similar, different forms of OST can result in different experiences, it is important to consider all the options when prescribing, or when being prescribed, OST
Not all OSTs are created equal.
The core function of most opioid substitution therapies (OST again) is to prevent opioid withdrawal, to minimise craving and to prevent use of illicit opioid drugs – usually heroin. The experiences of taking different forms of OST vary, and therefore so do the people for whom those medications are appropriate. There is some prior qualitative research into these differences from Neale and colleagues whose decision-making checklist is worth checking out.
Today’s article, by Parsons and colleagues [full citation below], is based on qualitative research with 14 people. As qualitative research, it cannot determine whether prolonged release buprenorphine is, or is not, as effective as regular buprenorphine or other forms of OST. The authors point to two randomised controlled trials (RCTs) that report on that issue. The study does, however, outline the impact that prolonged release buprenorphine can have on someone’s recovery. It is therefore a helpful piece of research for people who use drugs and for clinicians who want to make sure they recommend the appropriate medication.
“The benefit of being able to start the day without needing to consider one’s medication is worth noting and worthy of further research.”
Conflict of interests
But first, a note of caution. One of the authors is an employee of Camurus AB, another reports grants and personal fees from Camurus AB, and Camurus AB gave Turning Point (the employer of the first author) an unrestricted educational grant. Who is Camurus AB? Well, Camurus AB makes (among other things) prolonged release buprenorphine under the name of Buvidal.
This doesn’t mean that the results are false, or that they are biased, but it does mean that there is a high risk of bias. This perhaps begins to show when the authors talk about the ‘benefits, neutral and drawbacks’ of prolonged release buprenorphine. Those drawbacks are framed as ‘concerns’ and ‘questions’. All of which sounds very much like someone trying to avoid words like ‘negatives’ and ‘problems’. Anyway. There are whole libraries on the thorny subject of bias (and risk of bias), but for now, we should take it as a note of caution.
Practical implications
Caveats behind us, the results are interesting. Let’s start with practical experiences. It’s an injection, so some people were a bit sore around the injection site. There were some side effects such as teeth grinding, constipation and dehydration (is teeth grinding a ‘concern’ or a ‘question’?). These seemed to be of minimal ‘concern’ for most participants, several noting that they were less severe than those they experienced when using heroin.
The largest benefits reported in this study were from not having to attend a pharmacist (or similar) every day. It seems that having a weekly or monthly injection, allowed participants to ‘get on with’ their lives. There was a practical, as well as a psychological, side to this. One person said they only had to take a half day off work for the injection every month and could therefore avoid workplace questions about having to attend a daily appointment.
Psychological benefits
There were also psychological benefits. Several participants said that they did not feel like they were on medication. For them it was just a monthly appointment and little ongoing disruption to their lives. This contrasts with the experience of having daily, observed, medication at a pharmacist; a daily reminder that you are on OST.
Similarly, some said that having a monthly injection was beneficial to their recovery because they could, for the most part, avoid drug treatment services where they were likely to bump into old acquaintances – a trigger for relapse.
Another participant reported the benefit of not having to start the day being focused on their medication. Rather they could do… well, anything they wanted to, and could start thinking about it as soon as they woke up. I know this is different for many people, but the way I start my day can really linger. Burn the toast and it can take me all day (sometimes more) to shake it off. The benefit of being able to start the day without needing to consider one’s medication is worth noting and worthy of further research.
Some people were happy to be able to travel for a week (or longer) without having to pick up advance medication and without missing appointments – reducing the chance of then using illicit opioids. The suggestion running through this article is that is this sense of freedom that many found liberating and that was positive for their recovery. We must, here, remind ourselves briefly, and without prejudice, about the conflict of interest and the risk of bias.
Not for everyone
There are some small notes that are key. Some commented that prolonged release buprenorphine was only really appropriate for people who were already stable and who were ready for ‘the next stage’. This reminds us of the other differences between forms of OST that are not the focus of this piece. Many people benefit from having daily contact with a pharmacist. Some benefit from having a level or stable dose of medication, others prefer to feel changes throughout the day from the medication.
How to end treatment
The increased focus on prolonged release medications raises wider questions about addiction treatment. Rather than come off OST, then receive support until you are stable enough to move on, there are now opportunities for people to receive prolonged release buprenorphine as they move on. This could give someone enough support to prevent re-lapse whilst allowing them to move away from addiction treatment services. This won’t be appropriate for everyone, but it does provide a few more options and it is important to explore those options.
Not all OSTs are created equal. It is important to find the right match for the right person at the right time. If you, or someone you work with, is ready for reduced support, but is not yet ready to come off all OST, then this could be worth exploring.
That said, it’s worth keeping an eye out for some research that has been funded by someone with less of an interest in the outcomes. Which isn’t always easy, because people who are less interested in something are often also less likely to fund it. But that’s something for another post.
The original article can be found here:
Parsons, G., Ragbir, C., D’Agnone, O., Gibbs, A., Littlewood, R., & Hard, B. “Patient-Reported Outcomes, Experiences and Satisfaction with Weekly and Monthly Injectable Prolonged-Release Buprenorphine.” Substance Abuse and Rehabilitation 11 (2020): 41.
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