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Parkin S, Neale J, Strang J. 'Matters-of-concern' associated with discontinuation of long-acting injectable buprenorphine: Findings from a longitudinal qualitative study. THE INTERNATIONAL JOURNAL OF DRUG POLICY 2024; 129:104470. [PMID: 38843737 DOI: 10.1016/j.drugpo.2024.104470] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2023] [Revised: 05/17/2024] [Accepted: 05/18/2024] [Indexed: 08/09/2024]
Abstract
BACKGROUND Discontinuation of medications such as methadone and buprenorphine amongst patients receiving opioid agonist treatment (OAT) is an international phenomenon. Recent developments in OAT medication include depot-injections of buprenorphine. Circumstances underlying discontinuation of these new formulations of medication are not fully understood from a qualitative perspective. METHODS Data derive from a longitudinal qualitative study of patients' experience of long-acting injectable buprenorphine (LAIB), involving semi-structured telephone-interviews held at six-points in time. The relevant dataset for this article consists of 44 interview transcripts, generated from 8 participants who were each affected by discontinuation of LAIB prescriptions (during the first 12-months of treatment). Analyses sought to identify circumstances associated with LAIB discontinuation and data were further situated within a framework of 'evidence making intervention' and associated 'matters-of-concern'. Matters-of-concern relate to the ways in which an intervention is 'made' and constructed through engagement and practice, from the perspective of the recipient. FINDINGS In this study, participants experienced either 'discontinuation of LAIB prescriptions by treatment services' or patient-led 'opt-out' from treatment. Matters-of-concern underlying the former were associated with late attendance for scheduled appointments, non-prescribed substance use or receiving a custodial sentence. Matters-of-concern relating to patient-initiated discontinuation were associated with personal circumstances that affected treatment motivation, side-effects (of buprenorphine), a preference to resume heroin use, or because individual treatment goals had been achieved. CONCLUSION The assorted matters-of-concern that influence discontinuation of LAIB demonstrate that such OAT is complex and multi-faceted, is neither fixed nor stable, and does not generate universally shared outcome. Experiences of LAIB discontinuation are shaped by a wide range of social, temporal and treatment-related effects that include disconnected therapeutic alliance between patient and treatment providers. In order to maximise the benefits of LAIB it is necessary to develop meaningful therapeutic alliances (notwithstanding policy boundaries) to enable exploration of matters-of-concern during treatment.
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Affiliation(s)
- Stephen Parkin
- Department of Public Health, Environments and Society, London School of Hygiene and Tropical Medicine, London, UK.
| | - Joanne Neale
- National Addiction Centre, Institute of Psychiatry, Psychology & Neuroscience, King's College London, SE5 8BB, UK; Centre for Social Research in Health, University of New South Wales, NSW 2052, Australia
| | - John Strang
- National Addiction Centre, Institute of Psychiatry, Psychology & Neuroscience, King's College London, SE5 8BB, UK; South London & Maudsley (SLaM) NHS Foundation Trust, London SE5 8AZ, UK
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Daglish MRC, Hayllar JS, McDonough M. An Australian retrospective observational cohort comparison of the use of long-acting injectable buprenorphine products. JOURNAL OF SUBSTANCE USE AND ADDICTION TREATMENT 2024; 162:209348. [PMID: 38494054 DOI: 10.1016/j.josat.2024.209348] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/16/2023] [Revised: 01/16/2024] [Accepted: 02/21/2024] [Indexed: 03/19/2024]
Abstract
INTRODUCTION In early 2019, Australia became the first jurisdiction to have two brands of long-acting injectable buprenorphine (LAI-B) products available. Previously published studies have mostly followed pre-planned dosing schedules and seldom compared use of both products. This study presents a retrospective analysis of the "real-world" dosing requirements of patients on LAI-B. METHOD Five clinics provided data for patients commenced on LAI-B between 1 February 2019 and 30 June 2021 for buprenorphine doses and intervals between dosing. The study recorded basic demographic data including age, gender, and previous dose of transmucosal buprenorphine. The Local Institutional Ethics Committee provided approval. RESULTS Over 3600 individual doses (59 % Buvidal® & 41 % Sublocade®) were administered to 340 individual patients (median age 40 years, 63 % male), with the longest duration in treatment of 856 days. Median estimated duration of a treatment episode was 16.5 months (95%CI: 14.3-19.1). Approximately 94 % transferred from transmucosal buprenorphine (median daily dose 16 mg, range 2-32 mg). Most common LAI-B doses were Sublocade® 100 mg (22.4 %) and Buvidal® Monthly 128 mg (21.5 %); Buvidal® Weekly 24 mg (0.8 %) was least used. 13 % transitioned between LAI-B products. Weekly dose intervals were a median 7 days and monthly doses were given a median of 28 days apart. Overall, 36 % discontinued LAI-B before the census date. DISCUSSIONS AND CONCLUSIONS Most patients who started LAI-B remained in treatment, with similar rates in both products. A small, but appreciable number of people switched brands, suggesting that it remains important to have treatment options available.
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Affiliation(s)
- Mark R C Daglish
- Hospital Alcohol & Drug Service, Royal Brisbane & Women's Hospital, Metro North Heath, Brisbane, Australia; Alcohol & Drug Service, The Prince Charles Hospital, Metro North Health, Brisbane, Australia; Faculty of Medicine, The University of Queensland, Brisbane, Australia.
| | - Jeremy S Hayllar
- Alcohol & Drug Service, The Prince Charles Hospital, Metro North Health, Brisbane, Australia
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Gorman JA, Lindvig-Springborn A, Lee J, Khazanov GK, DePhilippis D. Adherence to buprenorphine-XR through hybrid telehealth contingency management procedures: a case series. JOURNAL OF SUBSTANCE USE 2024; 2024:1-6. [PMID: 39055109 PMCID: PMC11271741 DOI: 10.1080/14659891.2024.2351019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2023] [Accepted: 04/24/2024] [Indexed: 07/27/2024]
Abstract
Background and objectives Contingency management (CM) for substance use disorders (SUD) is effective in strengthening recovery behaviors, however can be quite burdensome. When health facilities experience staff shortages, adapting current CM protocols to be less staff and time intensive may be one way to address this challenge. Methods Case series (N = 3). Results Three veterans with opioid use disorder (OUD) received CM for treatment adherence through a Veteran Health Administration Outpatient Substance Disorder program. Due to the COVID-19 pandemic, traditional CM procedures resulted in limited accessibility and staff, delayed appointments, and decreased patient satisfaction. In response, the hybrid telehealth contingency management (HTCM) procedure was developed and implemented. Flexibility offered by HTCM allowed for consecutive completion of appointments and maintained adherence to BUP-XR treatment. Conclusions This is a novel method of CM implementation. HTCM streamlined the process and was successful in increasing accessibility, reducing time-burden on patients and staff, while preserving fidelity to key components of the model. Considerations for future implementation and implications of HTCM are discussed.
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Affiliation(s)
- Jay A. Gorman
- VISN 1 Mental Illness Research, Education, and Clinical Center (MIRECC), VA Bedford Healthcare System, Bedford, Massachusetts, USA
- Department of Psychiatry, Boston University School of Medicine, Boston, Massachusetts, USA
| | | | - Jonathan Lee
- VISN 1 Mental Illness Research, Education, and Clinical Center (MIRECC), VA Bedford Healthcare System, Bedford, Massachusetts, USA
- Department of Psychiatry, University of Massachusetts Chan Medical School, Worcester, Massachusetts, USA
| | - Gabriela K. Khazanov
- Center of Excellence for Substance Addiction Treatment & Education, Crescenz Veterans Affairs Medical Center, Philadelphia, Pennsylvania, USA
- Department of Psychiatry, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Dominick DePhilippis
- Department of Psychiatry, University of Pennsylvania, Philadelphia, Pennsylvania, USA
- U.S. Department of Veteran Affairs, Office of Mental Health and Suicide Prevention, Washington, District of Columbia, USA
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Hubbell A, Aghenta E, Jones C, Specker S. Extended-release buprenorphine in pregnancy. Am J Addict 2024; 33:354-356. [PMID: 38264845 DOI: 10.1111/ajad.13518] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2023] [Revised: 11/20/2023] [Accepted: 12/31/2023] [Indexed: 01/25/2024] Open
Abstract
BACKGROUND AND OBJECTIVES The relative safety and efficacy of monthly extended-release buprenorphine (XR-BUP) has not been fully evaluated in pregnant persons. METHODS Case report of two pregnant individuals receiving XR-BUP while pregnant. RESULTS Both patients had positive experiences and healthy infants. DISCUSSION AND CONCLUSIONS Sparse data regarding the use of XR-BUP in pregnant patients limits shared decision-making. Additional evidence will support the growing population of pregnant patients exposed to XR-BUP. SCIENTIFIC SIGNIFICANCE Positive patient experiences using XR-BUP during pregnancy have been previously unreported. This report will contribute to discussions of risks and benefits for future patients using XR-BUP during pregnancy.
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Affiliation(s)
- Alexander Hubbell
- M Health Fairview Addiction Medicine, University of Minnesota, Minneapolis, Minnesota, USA
| | - Ese Aghenta
- Department of Psychiatry, University of Minnesota, Minneapolis, Minnesota, USA
| | - Cresta Jones
- Department of Obstetrics, Gynecology, and Women's Health, University of Minnesota, Minneapolis, Minnesota, USA
| | - Sheila Specker
- Department of Psychiatry, University of Minnesota, Minneapolis, Minnesota, USA
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Farrell M, Shahbazi J, Chambers M, Byrne M, Gholami J, Zahra E, Grebely J, Lintzeris N, Larance B, Ali R, Nielsen S, Dunlop A, Dore GJ, McDonough M, Montebello M, Weiss R, Rodgers C, Cook J, Degenhardt L. 96-week retention in treatment with extended-release subcutaneous buprenorphine depot injections among people with opioid dependence: Extended follow-up after a single-arm trial. THE INTERNATIONAL JOURNAL OF DRUG POLICY 2024; 127:104390. [PMID: 38522175 DOI: 10.1016/j.drugpo.2024.104390] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2023] [Revised: 03/07/2024] [Accepted: 03/07/2024] [Indexed: 03/26/2024]
Abstract
BACKGROUND The most recent formulation of buprenorphine treatment is extended-release depot injections (BUP-XR) that are administered subcutaneously by health care professionals. This study aimed to observe treatment outcomes of BUP-XR delivered in standard practice during a 96-week follow-up period in a community setting. METHODS This study is an extension of the CoLAB study, a prospective single-arm, multicentre, open label trial (N=100, 7 sites in Australia) among people with opioid dependence who received monthly injections of BUP-XR to evaluate the retention in treatment. Participants were followed for 96 weeks, comprising 48 weeks of the CoLAB study followed by a 48-week extension. RESULTS Of 100 participants at baseline, 47 were retained on BUP-XR at 96 weeks. The median time retained on monthly depot was 90 weeks. Heroin use (adjusted OR=0.19, P=0.012) in the month prior to baseline was associated with lower odds of retention on BUP-XR. Older age at first opioid use (adjusted OR= 1.08, P=0.009) and longer duration in OAT at baseline (adjusted OR= 1.12, P=0.001) were associated with increased retention. Prevalence of past four-weeks opioid use was estimated at 4% at 96 weeks of treatment (prevalence 0.04, 95%CI: 0.00-0.11) compared to 15% at baseline. Quality of life and medication treatment satisfaction improved over time for those retained in treatment. CONCLUSION This is one of the few studies to describe long term (96 week) retention in treatment with BUP-XR in a community setting. It displayed retention rates with 47% of participants completing 96 weeks of treatment with BUP-XR. Patient reported outcomes suggest improvements in client wellbeing. FUNDING Indivior.
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Affiliation(s)
| | | | - Mark Chambers
- National Drug and Alcohol Research Centre, UNSW, Australia
| | - Marianne Byrne
- National Drug and Alcohol Research Centre, UNSW, Australia; The Kirby Institute, UNSW, Australia
| | - Jaleh Gholami
- National Drug and Alcohol Research Centre, UNSW, Australia
| | - Emma Zahra
- National Drug and Alcohol Research Centre, UNSW, Australia
| | | | - Nicholas Lintzeris
- Discipline of Addiction Medicine, University of Sydney, NSW, Australia; Drug and Alcohol Services, South East Sydney Local Health District, Surry Hills, NSW, Australia
| | - Briony Larance
- National Drug and Alcohol Research Centre, UNSW, Australia; School of Psychology, University of Wollongong, Wollongong, NSW, Australia
| | - Robert Ali
- National Drug and Alcohol Research Centre, UNSW, Australia; Faculty of Health and Medical Sciences, University of Adelaide, Adelaide, South Australia, Australia
| | - Suzanne Nielsen
- National Drug and Alcohol Research Centre, UNSW, Australia; Monash Addiction Research Centre, Eastern Health Clinical School, Monash University Peninsula Campus, Frankston, Victoria, Australia
| | - Adrian Dunlop
- Drug and Alcohol Clinical Services, Hunter New England Local Health District, Newcastle, NSW, Australia; Hunter Medical Research Institute, University of Newcastle, Newcastle, NSW, Australia
| | | | - Michael McDonough
- Drug and Alcohol Services South Australia, Adelaide, South Australia, Australia
| | - Mark Montebello
- National Drug and Alcohol Research Centre, UNSW, Australia; Discipline of Addiction Medicine, University of Sydney, NSW, Australia; Drug and Alcohol Services, North Sydney Local Health District, St Leonards, NSW, Australia
| | - Rob Weiss
- Frankston Healthcare, Frankston, Victoria, Australia
| | - Craig Rodgers
- Alcohol and Drug Service, St Vincent's Hospital, Darlinghurst NSW Australia
| | - Jon Cook
- Drug and Alcohol Clinical Advisory Service, Western Health, Victoria, Australia
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Lancaster K, Gendera S, Treloar C, Rhodes T, Shahbazi J, Byrne M, Nielsen S, Degenhardt L, Farrell M. Tinkering with care: Implementing extended-release buprenorphine depot treatment for opioid dependence. THE INTERNATIONAL JOURNAL OF DRUG POLICY 2024; 126:104359. [PMID: 38382354 DOI: 10.1016/j.drugpo.2024.104359] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2023] [Revised: 02/08/2024] [Accepted: 02/12/2024] [Indexed: 02/23/2024]
Abstract
We examine how extended-release buprenorphine depot (BUP-XR) is put to use and made to work in implementation practices, attending to how care practices are challenged and adapted as a long-acting technology is introduced into service in opioid agonist treatment (OAT) in Australia. Our approach is informed by ideas in science and technology studies (STS) emphasising the irreducible entanglement of care practices and technology, and in particular the concept of 'tinkering' as a practice of adaptation. To make our analysis, we draw on qualitative interview accounts (n = 19) of service providers involved in BUP-XR implementation across five sites. Our analysis considers the disruptive novelty of BUP-XR. Tinkering to make a novel technology work in practice slows down the expectation of implementation in relation to transformative innovation, despite the promise of dramatic or rapid change. Tinkering allowed for more open relations, for new care practices that departed from the routine and familiar, opening potential for how BUP-XR could be put to use and made to work in its new situation, and as its situation evolved along-with its implementation. Flexibility and openness of altering relations was, however, at times, held in tension with inflexibility and closure. This analysis identifies a concern for what is made present and what is made absent in the altered care network affected by BUP-XR, with the multiple effects of supervised daily dosing practices thrown into relief as they become absented. Tinkering to implement BUP-XR locally connects with a broader assemblage of trial and movement in the constitution of treatment. The introduction of long-acting technologies prompts new questions about embedded implementation practices, including supervised dosing, urinalysis, the time and place of psychosocial support, and how other social aspects of care might be recalibrated in drug treatment.
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Affiliation(s)
- K Lancaster
- Centre for Social Research in Health, University of New South Wales, Sydney, Australia; Goldsmiths, University of London, UK.
| | - S Gendera
- Social Policy Research Centre, University of New South Wales, Sydney, Australia
| | - C Treloar
- Centre for Social Research in Health, University of New South Wales, Sydney, Australia
| | - T Rhodes
- Centre for Social Research in Health, University of New South Wales, Sydney, Australia; London School of Hygiene and Tropical Medicine, UK
| | - J Shahbazi
- National Drug and Alcohol Research Centre, University of New South Wales, Sydney, Australia
| | - M Byrne
- National Drug and Alcohol Research Centre, University of New South Wales, Sydney, Australia
| | - S Nielsen
- Monash Addiction Research Centre, Monash University, Melbourne, Australia
| | - L Degenhardt
- National Drug and Alcohol Research Centre, University of New South Wales, Sydney, Australia
| | - M Farrell
- National Drug and Alcohol Research Centre, University of New South Wales, Sydney, Australia
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Bharat C, Chidwick K, Gisev N, Farrell M, Ali R, Degenhardt L. Trends in use of medicines for opioid agonist treatment in Australia, 2013-2022. THE INTERNATIONAL JOURNAL OF DRUG POLICY 2024; 123:104255. [PMID: 38029481 DOI: 10.1016/j.drugpo.2023.104255] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2023] [Revised: 09/26/2023] [Accepted: 10/29/2023] [Indexed: 12/01/2023]
Abstract
BACKGROUND There are limited longitudinal data on national patterns of opioid agonist treatment (OAT). This study describes 10-year trends in the sales of OAT medicines in Australia. METHODS A descriptive and time-series analysis of methadone, sublingual (SL) buprenorphine (+/-naloxone), and long-acting injectable (LAI) buprenorphine sold in Australia between 2013 and 2022 was performed. Total units sold were converted into an estimate of the number of clients that could be treated over a 28-day period with that amount of medicine ('client-months'). RESULTS Between January 2013 and December 2022, the estimated number of client-months on: any OAT increased by 50 % to 53,501, methadone decreased (-8.5%), SL buprenorphine increased (+78%), and LAI buprenorphine increased substantially after September 2019. In January 2013, 78 % of OAT client-months received methadone. By December 2022, 48 % received methadone, 26 % SL buprenorphine, and 26 % LAI buprenorphine. Between 2013 to 2022, OAT client-months per capita were highest in the state of New South Wales. Over the study period, greater increases in OAT were observed in very remote areas (88%) compared to major cities (53%). The number of client-months in non-community pharmacy settings remained stable from 2013 to 2019/20, before increasing markedly. The introduction of LAI buprenorphine was associated with an immediate, sustained increase of 1,636 OAT client-months, and further increases of 190 OAT client-months each month. CONCLUSION Patterns of OAT have shifted over the last 10-years with buprenorphine (SL/LAI) now the most common OAT used in Australia. The introduction of LAI buprenorphine has expanded OAT access, particularly in non-community pharmacy settings, and in remote areas.
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Affiliation(s)
- Chrianna Bharat
- National Drug and Alcohol Research Centre, UNSW Sydney, Randwick, NSW, Australia.
| | - Kendal Chidwick
- National Drug and Alcohol Research Centre, UNSW Sydney, Randwick, NSW, Australia
| | - Natasa Gisev
- National Drug and Alcohol Research Centre, UNSW Sydney, Randwick, NSW, Australia
| | - Michael Farrell
- National Drug and Alcohol Research Centre, UNSW Sydney, Randwick, NSW, Australia
| | - Robert Ali
- National Drug and Alcohol Research Centre, UNSW Sydney, Randwick, NSW, Australia; Faculty of Health and Medical Sciences, University of Adelaide, Adelaide, Australia
| | - Louisa Degenhardt
- National Drug and Alcohol Research Centre, UNSW Sydney, Randwick, NSW, Australia
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Iacono A, Wang T, Tadrous M, Campbell T, Kolla G, Leece P, Sproule B, Kleinman RA, Besharah J, Munro C, Doolittle M, Gomes T. Characteristics, treatment patterns and retention with extended-release subcutaneous buprenorphine for opioid use disorder: A population-based cohort study in Ontario, Canada. Drug Alcohol Depend 2024; 254:111032. [PMID: 38043224 DOI: 10.1016/j.drugalcdep.2023.111032] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/05/2023] [Revised: 11/10/2023] [Accepted: 11/11/2023] [Indexed: 12/05/2023]
Abstract
BACKGROUND Uptake and retention for opioid agonist treatment (OAT) remains low. Novel extended-release formulations may improve OAT accessibility by reducing the frequency of healthcare visits. Our aim was to examine uptake, characteristics, treatment patterns and retention of individuals initiating extended-release subcutaneous buprenorphine (BUP-ER), a monthly injectable OAT. METHODS We conducted a population-based cohort study among adults aged 18+ initiated on BUP-ER between February 3, 2020 and March 31, 2022 in Ontario, Canada. Using administrative health data, we defined continuous BUP-ER use based on repeat injections within a 56-day period and used Kaplan-Meier curves to estimate time on treatment. Among new BUP-ER recipients, we described individual and prescriber characteristics, healthcare utilization and treatment patterns. RESULTS 2366 individuals initiated BUP-ER. The median time to BUP-ER discontinuation was 183 days (interquartile range: 66-428 days) and 52.0% of individuals were co-prescribed buprenorphine/naloxone at least once throughout the period of BUP-ER receipt. Among individuals who initiated on a dose of 300mg BUP-ER and had three or more injections, 18.8% continued to receive only 300mg doses (N=276 of 1470). Furthermore, 28.6% of those whose dose was reduced to 100mg (N=341 of 1194) had a subsequent dose increase to 300mg. CONCLUSIONS On average, people initiating BUP-ER discontinue within the first 6 months of treatment. While BUP-ER is likely providing an important OAT option, the high occurrence of discontinuation, supplementation with buprenorphine/naloxone, and frequent dose increases suggest inadequacy of current dosing recommendations among a proportion of individuals.
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Affiliation(s)
- Anita Iacono
- Li Ka Shing Knowledge Institute of St. Michael's Hospital, 30 Bond Street, Toronto, Ontario M5B 1W8, Canada
| | - Tianru Wang
- ICES, V1 06, 2075 Bayview Avenue, Toronto, Ontario M4N 3M5, Canada
| | - Mina Tadrous
- University of Toronto Leslie Dan Faculty of Pharmacy, 144 College StToronto, Ontario M5S 3M2, Canada; ICES, V1 06, 2075 Bayview Avenue, Toronto, Ontario M4N 3M5, Canada; Women's College Hospital, 76 Grenville St Toronto, Ontario M5S 1B2, Canada
| | - Tonya Campbell
- Li Ka Shing Knowledge Institute of St. Michael's Hospital, 30 Bond Street, Toronto, Ontario M5B 1W8, Canada
| | - Gillian Kolla
- Canadian Institute for Substance Use Research, 2300 McKenzie Ave, Victoria, British Columbia V8N 5M8, Canada
| | - Pamela Leece
- Women's College Hospital, 76 Grenville St Toronto, Ontario M5S 1B2, Canada; University of Toronto Department of Family and Community Medicine, 500 University Ave, Toronto, Ontario M5G 1V7, Canada; Public Health Ontario, 480 University Ave #300, Toronto, Ontario M5G 1V2, Canada; University of Toronto Dalla Lana School of Public Health, 155 College St Room 500, Toronto, Ontario M5T 3M7, Canada
| | - Beth Sproule
- University of Toronto Leslie Dan Faculty of Pharmacy, 144 College StToronto, Ontario M5S 3M2, Canada; Centre for Addiction and Mental Health, 250 College St, Toronto, Ontario M5T 1R8, Canada; University of Toronto Department of Psychiatry, 250 College Street 8th floor, Toronto Ontario M5T 1R8, Canada
| | - Robert A Kleinman
- Centre for Addiction and Mental Health, 250 College St, Toronto, Ontario M5T 1R8, Canada; University of Toronto Department of Psychiatry, 250 College Street 8th floor, Toronto Ontario M5T 1R8, Canada
| | - Jes Besharah
- Li Ka Shing Knowledge Institute of St. Michael's Hospital, 30 Bond Street, Toronto, Ontario M5B 1W8, Canada; University of Toronto Leslie Dan Faculty of Pharmacy, 144 College StToronto, Ontario M5S 3M2, Canada; ICES, V1 06, 2075 Bayview Avenue, Toronto, Ontario M4N 3M5, Canada; University of Toronto Institute for Health Policy, Management and Evaluation, 155 College St 4th Floor, Toronto Ontario M5T 3M6, Canada; Women's College Hospital, 76 Grenville St Toronto, Ontario M5S 1B2, Canada; Centre for Addiction and Mental Health, 250 College St, Toronto, Ontario M5T 1R8, Canada; University of Toronto Department of Psychiatry, 250 College Street 8th floor, Toronto Ontario M5T 1R8, Canada; Canadian Institute for Substance Use Research, 2300 McKenzie Ave, Victoria, British Columbia V8N 5M8, Canada; University of Toronto Department of Family and Community Medicine, 500 University Ave, Toronto, Ontario M5G 1V7, Canada; Public Health Ontario, 480 University Ave #300, Toronto, Ontario M5G 1V2, Canada; University of Toronto Dalla Lana School of Public Health, 155 College St Room 500, Toronto, Ontario M5T 3M7, Canada; Ontario Drug Policy Research Network Lived Experience Advisory Group, St. Michael's Hospital, 30 Bond Street, Toronto, Ontario M5B 1W8, Canada
| | - Charlotte Munro
- Li Ka Shing Knowledge Institute of St. Michael's Hospital, 30 Bond Street, Toronto, Ontario M5B 1W8, Canada; University of Toronto Leslie Dan Faculty of Pharmacy, 144 College StToronto, Ontario M5S 3M2, Canada; ICES, V1 06, 2075 Bayview Avenue, Toronto, Ontario M4N 3M5, Canada; University of Toronto Institute for Health Policy, Management and Evaluation, 155 College St 4th Floor, Toronto Ontario M5T 3M6, Canada; Women's College Hospital, 76 Grenville St Toronto, Ontario M5S 1B2, Canada; Centre for Addiction and Mental Health, 250 College St, Toronto, Ontario M5T 1R8, Canada; University of Toronto Department of Psychiatry, 250 College Street 8th floor, Toronto Ontario M5T 1R8, Canada; Canadian Institute for Substance Use Research, 2300 McKenzie Ave, Victoria, British Columbia V8N 5M8, Canada; University of Toronto Department of Family and Community Medicine, 500 University Ave, Toronto, Ontario M5G 1V7, Canada; Public Health Ontario, 480 University Ave #300, Toronto, Ontario M5G 1V2, Canada; University of Toronto Dalla Lana School of Public Health, 155 College St Room 500, Toronto, Ontario M5T 3M7, Canada; Ontario Drug Policy Research Network Lived Experience Advisory Group, St. Michael's Hospital, 30 Bond Street, Toronto, Ontario M5B 1W8, Canada
| | - McCaffrey Doolittle
- Li Ka Shing Knowledge Institute of St. Michael's Hospital, 30 Bond Street, Toronto, Ontario M5B 1W8, Canada; University of Toronto Leslie Dan Faculty of Pharmacy, 144 College StToronto, Ontario M5S 3M2, Canada; ICES, V1 06, 2075 Bayview Avenue, Toronto, Ontario M4N 3M5, Canada; University of Toronto Institute for Health Policy, Management and Evaluation, 155 College St 4th Floor, Toronto Ontario M5T 3M6, Canada; Women's College Hospital, 76 Grenville St Toronto, Ontario M5S 1B2, Canada; Centre for Addiction and Mental Health, 250 College St, Toronto, Ontario M5T 1R8, Canada; University of Toronto Department of Psychiatry, 250 College Street 8th floor, Toronto Ontario M5T 1R8, Canada; Canadian Institute for Substance Use Research, 2300 McKenzie Ave, Victoria, British Columbia V8N 5M8, Canada; University of Toronto Department of Family and Community Medicine, 500 University Ave, Toronto, Ontario M5G 1V7, Canada; Public Health Ontario, 480 University Ave #300, Toronto, Ontario M5G 1V2, Canada; University of Toronto Dalla Lana School of Public Health, 155 College St Room 500, Toronto, Ontario M5T 3M7, Canada; Ontario Drug Policy Research Network Lived Experience Advisory Group, St. Michael's Hospital, 30 Bond Street, Toronto, Ontario M5B 1W8, Canada
| | - Tara Gomes
- Li Ka Shing Knowledge Institute of St. Michael's Hospital, 30 Bond Street, Toronto, Ontario M5B 1W8, Canada; University of Toronto Leslie Dan Faculty of Pharmacy, 144 College StToronto, Ontario M5S 3M2, Canada; ICES, V1 06, 2075 Bayview Avenue, Toronto, Ontario M4N 3M5, Canada; University of Toronto Institute for Health Policy, Management and Evaluation, 155 College St 4th Floor, Toronto Ontario M5T 3M6, Canada.
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Marsden J, Kelleher M, Gilvarry E, Mitcheson L, Bisla J, Cape A, Cowden F, Day E, Dewhurst J, Evans R, Hardy W, Hearn A, Kelly J, Lowry N, McCusker M, Murphy C, Murray R, Myton T, Quarshie S, Vanderwaal R, Wareham A, Hughes D, Hoare Z. Superiority and cost-effectiveness of monthly extended-release buprenorphine versus daily standard of care medication: a pragmatic, parallel-group, open-label, multicentre, randomised, controlled, phase 3 trial. EClinicalMedicine 2023; 66:102311. [PMID: 38045803 PMCID: PMC10692661 DOI: 10.1016/j.eclinm.2023.102311] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/08/2023] [Revised: 10/26/2023] [Accepted: 10/26/2023] [Indexed: 12/05/2023] Open
Abstract
Background Daily methadone maintenance or buprenorphine treatment is the standard-of-care (SoC) medication for opioid use disorder (OUD). Subcutaneously injected, extended-release buprenorphine (BUP-XR) may be more effective-but there has been no superiority evaluation. Methods This pragmatic, parallel-group, open-label, multi-centre, effectiveness superiority randomised, controlled, phase 3 trial was conducted at five National Health Service community-based treatment clinics in England and Scotland. Participants (adults aged ≥ 18 years; all meeting DSM-5 diagnostic criteria for moderate or severe OUD at admission to their current maintenance treatment episode) were randomly assigned (1:1) to receive continued daily SoC (liquid methadone (usual dose range: 60-120 mg) or sublingual/transmucosal buprenorphine (usual dose range: 8-24 mg) for 24 weeks; or monthly BUP-XR (Sublocade;® two injections of 300 mg, then four maintenance injections of 100 mg or 300 mg, with maintenance dose selected by response and preference) for 24 weeks. In the intent-to-treat population (senior statistician blinded to blinded to treatment group allocation), and with a seven-day grace period after randomisation, the primary endpoint was the count of days abstinent from non-medical opioids between days 8-168 (i.e., weeks 2-24; range: 0-161 days). Safety was reported for the intention-to- treat population. Adopting a broad societal perspective inclusive of criminal justice, NHS and personal social service costs, a trial-based cost-utility analysis estimated the Incremental Cost-effectiveness Ratio (ICER) per quality-adjusted life year (QALY) of BUP-XR versus SoC at the National Institute for Health and Care Excellence threshold. The study was registered EudraCT (2018-004460-63) and ClinicalTrials.gov (NCT05164549), and is completed. Findings Between Aug 9, 2019 and Nov 2, 2021, 314 participants were randomly allocated to receive SoC (n = 156) or BUP-XR (n = 158). Participants were abstinent from opioids for an adjusted mean of 104.37 days (standard error [SE] 9.89; range: 0-161 days) in the SoC group and an adjusted mean of 123.43 days (SE 4.76; range: 24-161 days) in the BUP-XR group (adjusted incident rate ratio [IRR] 1.18, 95% confidence interval [CI] 1.05-1.33; p-value 0.004). The incidence of any adverse event was higher in the BUP-XR group than the SoC group (128 [81.0%] of 158 participants versus 67 [42.9%] of 156 participants, respectively-most commonly rapidly-resolving (mild-moderate range) pain from drug administration in the BUP-XR group (121 [26.9%] of 450 adverse events). There were 11 serious adverse events (7.0%) in the 158 participants in the BUP-XR group, and 18 serious adverse events (11.5%) in the 156 participants in the SoC group-none judged to be related to study treatment. The BUP-XR treatment group had a mean incremental cost of £1033 (95% central range [CR] -1189 to 3225) and was associated with a mean incremental QALY of 0.02 (95% CR 0.00-0.05), and an ICER of £47,540 (0.37 probability of being cost-effective at the £30,000/QALY gained willingness-to-pay threshold). However, BUP-XR dominated the SoC among participants who were rated more severe at study baseline, and among participants in maintenance treatment for more that 28 days at study enrolment. Interpretation Evaluated against the daily oral SoC, monthly BUP-XR is clinically superior, delivering greater abstinence from opioids, and with a comparable safety profile. BUP-XR was not cost-effective in a base case cost-utility analysis using the societal perspective, but it was more effective and less costly (dominant) among participants with more severe OUD, or those whose current treatment episode was longer than 28 days. Further trials are needed to evaluate if BUP-XR is associated with better clinical and health economic outcomes over the longer term. Funding Indivior.
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Affiliation(s)
- John Marsden
- Addictions Department, School of Academic Psychiatry, Institute of Psychiatry, Psychology and Neuroscience, King’s College London, United Kingdom
- South London and Maudsley NHS Foundation Trust, United Kingdom
| | - Mike Kelleher
- Addictions Department, School of Academic Psychiatry, Institute of Psychiatry, Psychology and Neuroscience, King’s College London, United Kingdom
- South London and Maudsley NHS Foundation Trust, United Kingdom
| | - Eilish Gilvarry
- Cumbria, Northumberland, Tyne and Wear NHS Foundation Trust, Newcastle Addictions Service, Newcastle Upon Tyne, United Kingdom
| | - Luke Mitcheson
- Addictions Department, School of Academic Psychiatry, Institute of Psychiatry, Psychology and Neuroscience, King’s College London, United Kingdom
- South London and Maudsley NHS Foundation Trust, United Kingdom
| | - Jatinder Bisla
- King’s Clinical Trials Unit, Research Management and Innovation Directorate, King’s College London, United Kingdom
| | - Angela Cape
- King’s Clinical Trials Unit, Research Management and Innovation Directorate, King’s College London, United Kingdom
| | - Fiona Cowden
- NHS Tayside and Dundee Health and Social Care Partnership, Scotland, United Kingdom
| | - Edward Day
- Birmingham and Solihull Mental Health, NHS Foundation Trust, Birmingham, United Kingdom
| | - Jonathan Dewhurst
- Addictions Division, Greater Manchester Mental Health NHS Foundation Trust, Manchester, United Kingdom
| | - Rachel Evans
- School of Health Sciences, Bangor University, Wales, United Kingdom
| | - Will Hardy
- Clinic for Health Economics and Medicines Evaluation, Bangor University, Wales, United Kingdom
| | - Andrea Hearn
- Cumbria, Northumberland, Tyne and Wear NHS Foundation Trust, Newcastle Addictions Service, Newcastle Upon Tyne, United Kingdom
| | - Joanna Kelly
- King’s Clinical Trials Unit, Research Management and Innovation Directorate, King’s College London, United Kingdom
| | - Natalie Lowry
- Addictions Department, School of Academic Psychiatry, Institute of Psychiatry, Psychology and Neuroscience, King’s College London, United Kingdom
- South London and Maudsley NHS Foundation Trust, United Kingdom
| | - Martin McCusker
- Lambeth Service User Council, South London and Maudsley NHS Foundation Trust, United Kingdom
| | - Caroline Murphy
- King’s Clinical Trials Unit, Research Management and Innovation Directorate, King’s College London, United Kingdom
| | - Robert Murray
- Cumbria, Northumberland, Tyne and Wear NHS Foundation Trust, Newcastle Addictions Service, Newcastle Upon Tyne, United Kingdom
| | - Tracey Myton
- Addictions Division, Greater Manchester Mental Health NHS Foundation Trust, Manchester, United Kingdom
| | - Sophie Quarshie
- Cumbria, Northumberland, Tyne and Wear NHS Foundation Trust, Newcastle Addictions Service, Newcastle Upon Tyne, United Kingdom
| | - Rob Vanderwaal
- South London and Maudsley NHS Foundation Trust, United Kingdom
| | - April Wareham
- Patient and Public Involvement and Engagement Representative, United Kingdom
| | - Dyfrig Hughes
- Clinic for Health Economics and Medicines Evaluation, Bangor University, Wales, United Kingdom
| | - Zoë Hoare
- School of Health Sciences, Bangor University, Wales, United Kingdom
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Parkin S, Neale J, Strang J. Conceptualising retention in treatment with long-acting injectable buprenorphine (for opioid use disorder) as a journey: Findings from a longitudinal qualitative study. THE INTERNATIONAL JOURNAL OF DRUG POLICY 2023; 122:104221. [PMID: 37865052 DOI: 10.1016/j.drugpo.2023.104221] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2023] [Revised: 09/22/2023] [Accepted: 09/27/2023] [Indexed: 10/23/2023]
Abstract
BACKGROUND Conceptualisations of the 'patient journey' are popular within health service research. Patient journeys provide a person-centred approach to health care that typically prioritise subjective patient experience with the aim of improving relevant forms of intervention. This article explores the conceptualisation of retention in treatment for opioid use disorder (OUD) using long-acting injectable buprenorphine (LAIB) as a journey. METHODS Data derive from a longitudinal qualitative study, involving semi-structured interviews (held at six time-points), with participants who each initiated LAIB for the first time. Data analysis for this article focuses exclusively upon the experiences of those who had continued with LAIB treatment throughout one year (11 participants). Framework and thematic narrative analyses of 64 interviews with 11 participants sought to identify 'retention-narratives' that would indicate a 'retention journey' associated with LAIB treatment. FINDINGS Shared treatment experiences consisted of three distinct phases (Withdrawal and Separation, Transformation, and Engagement) that progressed in a linear and intersecting manner through time. Each phase had features that defined treatment experiences at a given time but changed as treatment progressed. All 11 participants experienced multiple features within each of the three treatment phases and all participants reported separation from their respective service provider throughout the first 12 months of treatment. Although some valued the latter separation, most were dissatisfied by reduced levels of contact. CONCLUSION Retention in treatment for OUD with LAIB, for at least 12-months, can be conceptualised as a journey. This conceptualisation emphasises the benefits (and challenges) clinicians and patients may expect to encounter during the first year of a LAIB treatment programme. An added implication of conceptualising LAIB treatment in this manner is that optimal benefits of the medication (as observed by participants) began to emerge during 'months 7-12' of the retention journey.
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Affiliation(s)
- Stephen Parkin
- National Addiction Centre, Institute of Psychiatry, Psychology & Neuroscience, King's College London, SE5 8BB, UK.
| | - Joanne Neale
- National Addiction Centre, Institute of Psychiatry, Psychology & Neuroscience, King's College London, SE5 8BB, UK; Centre for Social Research in Health, University of New South Wales, NSW 2052, Australia
| | - John Strang
- National Addiction Centre, Institute of Psychiatry, Psychology & Neuroscience, King's College London, SE5 8BB, UK; South London & Maudsley (SLaM) NHS Foundation Trust, London SE5 8AZ, UK
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Lee K, Zhao Y, Merali T, Fraser C, Kozicky JM, Mormont MC, Conway B. Real-world Evidence for Impact of Opioid Agonist Therapy on Nonfatal Overdose in Patients with Opioid Use Disorder during the COVID-19 Pandemic. J Addict Med 2023; 17:e374-e381. [PMID: 37934531 DOI: 10.1097/adm.0000000000001213] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/13/2023]
Abstract
OBJECTIVES The primary objectives of this study were to describe the demographics and clinical characteristics of patients who were treated with buprenorphine extended-release versus buprenorphine-naloxone sublingual tablets versus methadone in a real-world setting and to evaluate the difference in nonfatal overdose events between treatment cohorts. METHODS This study was a retrospective chart review of patients with opioid use disorder initiating opioid agonist therapy in Canada during the outset of the COVID-19 pandemic (March 11, 2020 to October 31, 2021). Three treatment cohorts were defined by the initial prescribed opioid agonist therapy regimen: buprenorphine extended-release, buprenorphine-naloxone sublingual tablets, and methadone. Baseline characteristics, as well as treatment status, overdose events, and substance use 6 months after treatment initiation were collected using a standardized form. RESULTS Nine clinics provided data on 379 patient cases. The incidence rate (number of events per 100 person-years) for a self-reported nonfatal overdose was 46.8 (n = 18), 19.3 (n = 10), and 1.7 (n = 1) in the methadone, buprenorphine-naloxone sublingual tablets, and buprenorphine extended-release cohorts, respectively. The risk-adjusted difference for the proportion of patients with nonfatal overdose was 8.59% (95% confidence interval, 3.10-14.08%; P = 0.0022) for methadone versus buprenorphine extended-release and 6.51% (95% confidence interval, 1.46-11.56%; P = 0.0115) for buprenorphine-naloxone sublingual tablets versus buprenorphine extended-release. CONCLUSIONS Buprenorphine extended-release was associated with lower rates of nonfatal overdose events compared with daily opioid agonist therapy. Given the limitations of this naturalistic, retrospective design, further prospective studies are needed to validate these findings and demonstrate the potential for long-acting opioid agonist therapy in addressing the opioid crisis.
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Affiliation(s)
- Kenneth Lee
- From the London RAAM Clinic, London, ON, Canada (KL); Indivior Inc, Richmond, VA (YZ); Indivior Canada Ltd., Montreal, QC (J-MK, M-CM); Drug Intelligence Inc., Toronto, ON, Canada (TM); Cool Aid Community Health Center, Victoria, BC, Canada (CF); Novocure Inc, Portsmouth, NH (M-CM); Novocure Inc, Montreal, QC, Canada (M-CM); and Vancouver Infectious Diseases Center and Simon Fraser University, Burnaby, BC, Canada (BC)
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Abstract
This paper is the forty-fifth consecutive installment of the annual anthological review of research concerning the endogenous opioid system, summarizing articles published during 2022 that studied the behavioral effects of molecular, pharmacological and genetic manipulation of opioid peptides and receptors as well as effects of opioid/opiate agonists and antagonists. The review is subdivided into the following specific topics: molecular-biochemical effects and neurochemical localization studies of endogenous opioids and their receptors (1), the roles of these opioid peptides and receptors in pain and analgesia in animals (2) and humans (3), opioid-sensitive and opioid-insensitive effects of nonopioid analgesics (4), opioid peptide and receptor involvement in tolerance and dependence (5), stress and social status (6), learning and memory (7), eating and drinking (8), drug abuse and alcohol (9), sexual activity and hormones, pregnancy, development and endocrinology (10), mental illness and mood (11), seizures and neurologic disorders (12), electrical-related activity and neurophysiology (13), general activity and locomotion (14), gastrointestinal, renal and hepatic functions (15), cardiovascular responses (16), respiration and thermoregulation (17), and immunological responses (18).
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Affiliation(s)
- Richard J Bodnar
- Department of Psychology and Neuropsychology Doctoral Sub-Program, Queens College, City University of New York, Flushing, NY 11367, USA.
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13
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Parkin S, Neale J, Strang J. Non-Prescribed Substance Use during the First Month of Treatment by People Receiving Depot Buprenorphine for Opioid Use Disorder. Subst Use Misuse 2023; 58:1696-1706. [PMID: 37571999 DOI: 10.1080/10826084.2023.2244064] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 08/14/2023]
Abstract
Background: Non-prescribed substance use (NPSU) during the treatment of opioid use disorder (OUD) is a recognized phenomenon. The use of non-prescribed substances is associated with discontinuing treatment and drop-out can occur within the early weeks of treatment, before benefit from treatment occurs. Recent developments in treatment include long-acting, slow-release depot buprenorphine injections. This article focuses on NPSU during the first month of treatment with depot buprenorphine, addressing the frequency with which it occurs, the substances used, and reasons for use. Methods: 70 semi-structured interviews (held at three time-points) were conducted with 26 patients initiating depot buprenorphine as part of a longitudinal qualitative study. Analysis prioritized content and framework analyses. Findings: 17/26 participants self-reported NPSU at various times during the first month of treatment. NPSU typically involved heroin, crack-cocaine and some use of benzodiazepines and/or cannabis. Participants' reasons for heroin use were connected to their subjective accounts of opioid withdrawal symptoms, the management of pain, and experimentation (to test the blockade effect of buprenorphine). Frequency of heroin use was typically episodic rather than sustained. Participants associated crack-cocaine use with stimulant-craving and social connections, and considered their use of this substance to be difficult to manage. Conclusions: Patients' initial engagement with treatment for OUD is rarely examined in qualitative research. This study highlights how NPSU amongst patients receiving new forms of such treatment continues to be a challenge. As such, shared decision-making (between providers and patients) regarding treatment goals and NPSU should be central to the delivery of depot buprenorphine treatment programmes.
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Affiliation(s)
- Stephen Parkin
- Institute of Psychiatry, National Addiction Centre, King's College London, London, UK
| | - Joanne Neale
- Institute of Psychiatry, National Addiction Centre, King's College London, London, UK
- Centre for Social Research in Health, University of New South Wales, Kensington, Australia
| | - John Strang
- Institute of Psychiatry, National Addiction Centre, King's College London, London, UK
- South London & Maudsley (SLaM), NHS Foundation Trust, London, UK
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14
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Neale J, Parkin S, Strang J. Patients' goals when initiating long-acting injectable buprenorphine treatment for opioid use disorder: findings from a longitudinal qualitative study. Subst Abuse Treat Prev Policy 2023; 18:37. [PMID: 37349776 PMCID: PMC10288705 DOI: 10.1186/s13011-023-00551-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2023] [Accepted: 06/16/2023] [Indexed: 06/24/2023] Open
Abstract
BACKGROUND Long-acting injectable buprenorphine (LAIB) is a new treatment for opioid use disorder that has been introduced against an international policy backdrop of recovery and person-centred care. This paper explores the goals that people want to achieve from LAIB to identify potential implications for policy and practice. METHODS Data derive from longitudinal qualitative interviews conducted with 26 people (18 male; 8 female) initiating LAIB in England and Wales, UK (June 2021-March 2022). Participants were interviewed up to five times by telephone over six months (107 interviews in total). Transcribed interview data relating to each participant's treatment goals were coded, summarised in Excel, and then analysed via a process of Iterative Categorization. RESULTS Participants often articulated a desire to be abstinent without defining exactly what they meant by this. Most intended to reduce their dosage of LAIB but did not want to rush. Although participants seldom used the term 'recovery', almost all identified objectives consistent with current definitions of this concept. Participants articulated broadly consistent goals over time, although some extended the timeframes for achieving treatment-related goals at later interviews. At their last interview, most participants remained on LAIB, and there were reports that the medication was enabling positive outcomes. Despite this, participants were aware of the complex personal, service-level, and situational factors that hindered their treatment progress, understood the additional support they needed to achieve their goals, and voiced frustrations when services failed them. CONCLUSIONS There is a need for wider debate regarding the goals people initiating LAIB are seeking and the diverse range of positive treatment outcomes LAIB could potentially generate. Those providing LAIB should offer regular on-going contact and other forms of non-medical support so that patients have the best opportunity to succeed. Policies relating to recovery and person-centred care have previously been criticised for responsibilising patients and service users to take better care of themselves and to change their own lives. In contrast, our findings suggest that these policies may, in fact, be empowering people to expect a greater range of support as part of the package of care they receive from service providers.
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Affiliation(s)
- Joanne Neale
- National Addiction Centre, Institute of Psychiatry, Psychology & Neuroscience, King’s College London, London, SE5 8BB UK
- Centre for Social Research in Health, University of New South Wales, Sydney, NSW 2052 Australia
| | - Stephen Parkin
- National Addiction Centre, Institute of Psychiatry, Psychology & Neuroscience, King’s College London, London, SE5 8BB UK
| | - John Strang
- National Addiction Centre, Institute of Psychiatry, Psychology & Neuroscience, King’s College London, London, SE5 8BB UK
- South London & Maudsley (SLaM) NHS Foundation Trust, London, SE5 8AZ UK
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Degenhardt L, Clark B, Macpherson G, Leppan O, Nielsen S, Zahra E, Larance B, Kimber J, Martino-Burke D, Hickman M, Farrell M. Buprenorphine versus methadone for the treatment of opioid dependence: a systematic review and meta-analysis of randomised and observational studies. Lancet Psychiatry 2023; 10:386-402. [PMID: 37167985 DOI: 10.1016/s2215-0366(23)00095-0] [Citation(s) in RCA: 21] [Impact Index Per Article: 21.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/19/2023] [Revised: 03/01/2023] [Accepted: 03/02/2023] [Indexed: 05/13/2023]
Abstract
BACKGROUND Opioid dependence is associated with substantial health and social burdens, and opioid agonist treatment (OAT) is highly effective in improving multiple outcomes for people who receive this treatment. Methadone and buprenorphine are common medications provided as OAT. We aimed to examine buprenorphine compared with methadone in the treatment of opioid dependence across a wide range of primary and secondary outcomes. METHODS We did a systematic review and meta-analysis in accordance with GATHER and PRISMA guidelines. We searched Embase, MEDLINE, CENTRAL, and PsycINFO from database inception to Aug 1, 2022; clinical trial registries and previous relevant Cochrane reviews were also reviewed. We included all RCTs and observational studies of adults (aged ≥18 years) with opioid dependence comparing treatment with buprenorphine or methadone. Primary outcomes were retention in treatment at 1, 3, 6, 12, and 24 months, treatment adherence (measured through doses taken as prescribed, dosing visits attended, and biological measures), or extra-medical opioid use (measured by urinalysis and self-report). Secondary outcomes were use of benzodiazepines, cannabis, cocaine, amphetamines, and alcohol; withdrawal; craving; criminal activity and engagement with the criminal justice system; overdose; mental and physical health; sleep; pain; global functioning; suicidality and self-harm; and adverse events. Single-arm cohort studies and RCTs that collected data on buprenorphine retention alone were also reviewed. Data on study, participant, and treatment characteristics were extracted. Study authors were contacted to obtain additional data when required. Comparative estimates were pooled with use of random-effects meta-analyses. The proportion of individuals retained in treatment across multiple timepoints was pooled for each drug. This study is registered with PROSPERO (CRD42020205109). FINDINGS We identified 32 eligible RCTs (N=5808 participants) and 69 observational studies (N=323 340) comparing buprenorphine and methadone, in addition to 51 RCTs (N=11 644) and 124 observational studies (N=700 035) that reported on treatment retention with buprenorphine. Overall, 61 studies were done in western Europe, 162 in North America, 14 in north Africa and the Middle East, 20 in Australasia, five in southeast Asia, seven in south Asia, two in eastern Europe, three in central Europe, one in east Asia, and one in central Asia. 1 040 827 participants were included in these primary studies; however, gender was only reported for 572 111 participants, of whom 377 991 (66·1%) were male and 194 120 (33·9%) were female. Mean age was 37·1 years (SD 6·0). At timepoints beyond 1 month, retention was better for methadone than for buprenorphine: for example, at 6 months, the pooled effect favoured methadone in RCTs (risk ratio 0·76 [95% CI 0·67-0·85]; I·=74·2%; 16 studies, N=3151) and in observational studies (0·77 [0·68-0·86]; I·=98·5%; 21 studies, N=155 111). Retention was generally higher in RCTs than observational studies. There was no evidence suggesting that adherence to treatment differed with buprenorphine compared with methadone. There was some evidence that extra-medical opioid use was lower in those receiving buprenorphine in RCTs that measured this outcome by urinalysis and reported proportion of positive urine samples (over various time frames; standardised mean difference -0·20 [-0·29 to -0·11]; I·=0·0%; three studies, N=841), but no differences were found when using other measures. Some statistically significant differences were found between buprenorphine and methadone among secondary outcomes. There was evidence of reduced cocaine use, cravings, anxiety, and cardiac dysfunction, as well as increased treatment satisfaction among people receiving buprenorphine compared with methadone; and evidence of reduced hospitalisation and alcohol use in people receiving methadone. These differences in secondary outcomes were based on small numbers of studies (maximum five), and were often not consistent across study types or different measures of the same constructs (eg, cocaine use). INTERPRETATION Evidence from trials and observational studies suggest that treatment retention is better for methadone than for sublingual buprenorphine. Comparative evidence on other outcomes examined showed few statistically significant differences and was generally based on small numbers of studies. These findings highlight the imperative for interventions to improve retention, consideration of client-centred factors (such as client preference) when selecting between methadone and buprenorphine, and harmonisation of data collection and reporting to strengthen future syntheses. FUNDING Australian National Health and Medical Research Council.
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Affiliation(s)
- Louisa Degenhardt
- National Drug and Alcohol Research Centre, University of New South Wales, Sydney, NSW, Australia.
| | - Brodie Clark
- National Drug and Alcohol Research Centre, University of New South Wales, Sydney, NSW, Australia
| | - Georgina Macpherson
- National Drug and Alcohol Research Centre, University of New South Wales, Sydney, NSW, Australia
| | - Oscar Leppan
- National Drug and Alcohol Research Centre, University of New South Wales, Sydney, NSW, Australia
| | - Suzanne Nielsen
- Monash Addiction Research Centre, Monash University, Melbourne, VIC, Australia
| | - Emma Zahra
- National Drug and Alcohol Research Centre, University of New South Wales, Sydney, NSW, Australia
| | - Briony Larance
- School of Psychology and Illawarra Health and Medical Research Institute, University of Wollongong, Wollongong, NSW, Australia
| | - Jo Kimber
- National Drug and Alcohol Research Centre, University of New South Wales, Sydney, NSW, Australia
| | - Daniel Martino-Burke
- National Drug and Alcohol Research Centre, University of New South Wales, Sydney, NSW, Australia
| | - Matthew Hickman
- Population Health Science, Bristol Medical School, University of Bristol, Bristol, UK
| | - Michael Farrell
- National Drug and Alcohol Research Centre, University of New South Wales, Sydney, NSW, Australia
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Clay S, Treloar C, Degenhardt L, Grebely J, Christmass M, Gough C, Hayllar J, McDonough M, Henderson C, Crawford S, Farrell M, Marshall A. 'I just thought that was the best thing for me to do at this point': Exploring patient experiences with depot buprenorphine and their motivations to discontinue. THE INTERNATIONAL JOURNAL OF DRUG POLICY 2023; 115:104002. [PMID: 37003194 DOI: 10.1016/j.drugpo.2023.104002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2022] [Revised: 03/07/2023] [Accepted: 03/08/2023] [Indexed: 04/03/2023]
Abstract
INTRODUCTION Long-acting injectable depot buprenorphine is a recent addition to the suite of opioid agonist therapies (OAT) used to treat opioid use disorder (OUD). However, there has been little research that focuses on the lived experience of people receiving depot buprenorphine treatment and reasons for why people decide to discontinue. The aim of this study was to explore what it is like to receive depot buprenorphine and to understand the motivations behind why people discontinue. METHODS Open-ended, semi-structured interviews were conducted between November 2021 and January 2022 with individuals who were either currently receiving depot buprenorphine or had discontinued or were in the process of discontinuing depot buprenorphine. Liberati, et al.'s (2022) adaptation of Dixon-Woods's (2006) candidacy framework was used to analyse the participant experiences. RESULTS 40 participants (26 male, 13 female, 1 undisclosed; mean age 42 years) were interviewed about their experience with depot buprenorphine. At the time of the interview, 21 were currently receiving depot buprenorphine and 19 had discontinued this treatment or were in the process of discontinuing. Participants cited 4 key reasons why they decided to discontinue depot buprenorphine:1) feeling forced into the program, 2) experiencing negative side-effects, 3) finding the treatment ineffective, and 4) wanting to stop depot buprenorphine/OAT to use opioids again or feeling 'cured' and no longer in need of OAT. Participants were ultimately discussing issues related to clinician-patient power relations, agency and bodily autonomy, and the pursuit of well-being. CONCLUSION Depot buprenorphine remains a promising treatment for OUD and offers potential to improve treatment adherence. Instances of restricted OAT choice and consumer concerns regarding a lack of agency must be addressed in order to enhance therapeutic relationships. Clinicians and other healthcare workers in this field also need greater access to information about depot buprenorphine to better address issues patients face during treatment. More research is required to understand patient and treatment choice given the options of these new treatment formulations.
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Affiliation(s)
- Simon Clay
- National Drug & Alcohol Research Centre, University of New South Wales, Australia.
| | - Carla Treloar
- National Drug & Alcohol Research Centre, University of New South Wales, Australia
| | - Louisa Degenhardt
- National Drug & Alcohol Research Centre, University of New South Wales, Australia
| | - Jason Grebely
- National Drug & Alcohol Research Centre, University of New South Wales, Australia
| | - Michael Christmass
- National Drug & Alcohol Research Centre, University of New South Wales, Australia
| | - Chris Gough
- National Drug & Alcohol Research Centre, University of New South Wales, Australia
| | - Jeremy Hayllar
- National Drug & Alcohol Research Centre, University of New South Wales, Australia
| | - Mike McDonough
- National Drug & Alcohol Research Centre, University of New South Wales, Australia
| | - Charles Henderson
- National Drug & Alcohol Research Centre, University of New South Wales, Australia
| | - Sione Crawford
- National Drug & Alcohol Research Centre, University of New South Wales, Australia
| | - Michael Farrell
- National Drug & Alcohol Research Centre, University of New South Wales, Australia
| | - Alison Marshall
- National Drug & Alcohol Research Centre, University of New South Wales, Australia
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Rapid induction onto extended-release injectable buprenorphine following opioid overdose: A case series. DRUG AND ALCOHOL DEPENDENCE REPORTS 2023; 7:100144. [PMID: 37033158 PMCID: PMC10073633 DOI: 10.1016/j.dadr.2023.100144] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/06/2023] [Revised: 03/08/2023] [Accepted: 03/14/2023] [Indexed: 03/17/2023]
Abstract
Background Buprenorphine treatment has been associated with reduced non-prescribed opioid use and opioid related overdose (OD). We evaluated initial outcomes of rapid induction onto extended-release injectable buprenorphine (BUP-XR) within 7 days of emergency department presentation for unintentional OD. Methods Between February 2019-February 2021, N = 19 patients with opioid use disorder received buprenorphine/naloxone (4/1 mg), followed by BUP-XR (300 mg) at induction and continued BUP-XR outpatient for 6 months. Primary outcomes included adverse events, repeat OD, and death. Results For patients who received at least one dose of BUP-XR, there were no treatment related serious adverse events or symptoms of precipitated withdrawal. In addition, there were no repeat visits for ODs or deaths within 6 months of the initial OD. Discussion These preliminary findings support the need for larger controlled clinical trials to examine the safety and efficacy of rapid induction of BUP-XR in patients with opioid use disorder at high risk of opioid OD. Rapid induction onto long-lasting injectable buprenorphine may be a promising and protective treatment approach in the future.
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Neale J, Parkin S, Strang J. How do patients feel during the first 72 h after initiating long-acting injectable buprenorphine? An embodied qualitative analysis. Addiction 2023. [PMID: 36808168 DOI: 10.1111/add.16171] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/16/2022] [Accepted: 02/06/2023] [Indexed: 02/22/2023]
Abstract
BACKGROUND AND AIMS Long-acting injectable buprenorphine (LAIB) is a new treatment for opioid use disorder that is generating positive outcomes. Negative effects are typically mild and transient, but can occasionally be serious, resulting in treatment discontinuation/non-adherence. This paper aims to analyse patients' accounts of how they felt during the first 72 h after initiating LAIB. METHODS Semi-structured interviews were conducted (June 2021-March 2022) with 26 people (18 males and 8 females) who had started LAIB within the previous 72 h. Participants were recruited from treatment services in England and Wales and were interviewed by telephone using a topic guide. Interviews were audio-recorded, transcribed and coded. The concepts of embodiment and embodied cognition framed the analyses. Data on participants' substance use, initiation onto LAIB and feelings were tabulated. Next, participants' accounts of how they felt were analysed following the stages of Iterative Categorization. RESULTS Participants reported complex combinations of changing negative and positive feelings. Bodily experiences included withdrawal symptoms, poor sleep, injection-site pain/soreness, lethargy and heightened senses inducing nausea ('distressed bodies'), but also enhanced somatic wellbeing, improved sleep, better skin, increased appetite, reduced constipation and heightened senses inducing pleasure ('returning body functions'). Cognitive responses included anxiety, uncertainties and low mood/depression ('the mind in crisis') and improved mood, greater positivity and reduced craving ('feeling psychologically better'). Whereas most negative effects reported are widely recognized, the early benefits of treatment described are less well-documented and may be an overlooked distinctive feature of LAIB. CONCLUSIONS During the first 72 h after initiating long-acting injectable buprenorphine, new patients report experiencing a range of interconnected positive and negative short-term effects. Providing new patients with information about the range and nature of these effects can prepare them for what to expect and help them manage feelings and reduce anxiety. In turn, this may increase medication adherence.
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Affiliation(s)
- Joanne Neale
- National Addiction Centre, Institute of Psychiatry, Psychology & Neuroscience, King's College London, London, SE5 8BB, UK.,Centre for Social Research in Health, University of New South Wales, New South Wales, NSW 2052, Australia
| | - Stephen Parkin
- National Addiction Centre, Institute of Psychiatry, Psychology & Neuroscience, King's College London, London, SE5 8BB, UK
| | - John Strang
- National Addiction Centre, Institute of Psychiatry, Psychology & Neuroscience, King's College London, London, SE5 8BB, UK.,South London and Maudsley (SLaM) NHS Foundation Trust, London, SE5 8AZ, UK
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Cuperfain AB, Katznelson G, Costa T, Wong P, Beyraghi N, George TP, Lofwall MR, Chopra N. Factors to guide the use of extended-release buprenorphine formulations for specific patient populations. JOURNAL OF SUBSTANCE USE 2023. [DOI: 10.1080/14659891.2023.2174908] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/11/2023]
Affiliation(s)
- Ari B. Cuperfain
- Department of Psychiatry, Temerty Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Gali Katznelson
- Department of Obstetrics and Gynaecology, Temerty Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Tianna Costa
- Addictions Division and Centre for Complex Interventions, Centre for Addiction and Mental Health, University of Toronto, Toronto, Ontario, Canada
| | - Patrick Wong
- Addictions Division and Centre for Complex Interventions, Centre for Addiction and Mental Health, University of Toronto, Toronto, Ontario, Canada
| | - Narges Beyraghi
- Department of Psychiatry, Temerty Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
- Addictions Division and Centre for Complex Interventions, Centre for Addiction and Mental Health, University of Toronto, Toronto, Ontario, Canada
| | - Tony P. George
- Department of Psychiatry, Temerty Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
- Addictions Division and Centre for Complex Interventions, Centre for Addiction and Mental Health, University of Toronto, Toronto, Ontario, Canada
| | - Michelle R. Lofwall
- Departments of Behavioral Science and Psychiatry, Center on Drug and Alcohol Research, University of Kentucky College of Medicine, Lexington, Kentucky, USA
| | - Nitin Chopra
- Department of Psychiatry, Temerty Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
- Addictions Division and Centre for Complex Interventions, Centre for Addiction and Mental Health, University of Toronto, Toronto, Ontario, Canada
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History of the discovery, development, and FDA-approval of buprenorphine medications for the treatment of opioid use disorder. DRUG AND ALCOHOL DEPENDENCE REPORTS 2023; 6:100133. [PMID: 36994370 PMCID: PMC10040330 DOI: 10.1016/j.dadr.2023.100133] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/11/2022] [Revised: 01/06/2023] [Accepted: 01/09/2023] [Indexed: 01/12/2023]
Abstract
Buprenorphine-based medications were first approved by the United States Food and Drug Administration in 2002 for the treatment of opioid dependence, or opioid use disorder (OUD) as the condition is presently known. This regulatory milestone was the outcome of 36 years of research and development, which also led to the development and approval of several other new buprenorphine-based medications. In this short review, we first describe the discovery and early development stages of buprenorphine. Second, we review key steps that led to the development of buprenorphine as a drug product. Third, we explain the regulatory approval of several buprenorphine-based medications for the treatment of OUD. We also discuss these developments in the context of the evolution of regulations and policies that have progressively improved OUD treatment availability and efficacy, although challenges remain in removing system-level, provider-level, and local-level barriers to quality treatment, to integrating OUD treatment into routine care and other settings, to reducing disparities in access to treatment, and to optimizing person-centered outcomes.
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Laffont CM, Ngaimisi E, Gopalakrishnan M, Ivaturi V, Young M, Greenwald MK, Heidbreder C. Buprenorphine exposure levels to optimize treatment outcomes in opioid use disorder. Front Pharmacol 2022; 13:1052113. [PMID: 36467036 PMCID: PMC9715596 DOI: 10.3389/fphar.2022.1052113] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2022] [Accepted: 10/28/2022] [Indexed: 12/04/2023] Open
Abstract
The severity of the ongoing opioid crisis, recently exacerbated by the COVID-19 pandemic, emphasizes the importance for individuals suffering from opioid use disorder (OUD) to have access to and receive efficacious, evidence-based treatments. Optimal treatment of OUD should aim at blocking the effects of illicit opioids while controlling opioid craving and withdrawal to facilitate abstinence from opioid use and promote recovery. The present work analyses the relationship between buprenorphine plasma exposure and clinical efficacy in participants with moderate to severe OUD using data from two clinical studies (39 and 504 participants). Leveraging data from placebo-controlled measures assessing opioid blockade, craving, withdrawal and abstinence, we found that buprenorphine plasma concentrations sustained at 2-3 ng/ml (corresponding to ≥70% brain mu-opioid receptor occupancy) optimized treatment outcomes in the majority of participants, while some individuals (e.g., injecting opioid users) needed higher concentrations. Our work also included non-linear mixed effects modeling and survival analysis, which identified a number of demographic, genetic and social factors modulating treatment response and retention. Altogether, these findings provide key information on buprenorphine plasma levels that optimize clinical outcomes and increase the likelihood of individual treatment success. NLM identifiers: NCT02044094, NCT02357901.
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Affiliation(s)
| | - Eliford Ngaimisi
- Center for Translational Medicine, University of Maryland, Baltimore, MD, United States
| | | | - Vijay Ivaturi
- Center for Translational Medicine, University of Maryland, Baltimore, MD, United States
| | - Malcolm Young
- Indivior Inc., North Chesterfield, VA, United States
| | - Mark K. Greenwald
- Department of Psychiatry and Behavioral Neurosciences, Wayne State University School of Medicine, Detroit, MI, United States
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Mullen W, Hedberg M, Gadbois B, Heidbreder C. The introduction of a novel formulation of buprenorphine into organized health systems. DRUG AND ALCOHOL DEPENDENCE REPORTS 2022; 4:100090. [PMID: 36846578 PMCID: PMC9948815 DOI: 10.1016/j.dadr.2022.100090] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/07/2022] [Revised: 07/28/2022] [Accepted: 07/29/2022] [Indexed: 11/19/2022]
Abstract
Background Effective medications for opioid use disorder (MOUD) are underutilized. This exploratory study used real-world data to analyze US distribution patterns of buprenorphine extended-release (BUP-XR) within organized health systems (OHS), including the Veterans Health Administration (VHA), Indian Health Service (IHS), criminal justice system (CJS), and integrated delivery networks (IDNs). Methods National BUP-XR distribution data within each OHS were available from WNS Global Services and were evaluated from July 2019 through July 2020. BUP-XR distribution data by OHS subtype (VHA, IHS, CJS, IDN) and state were aggregated and reported. Results The total distribution of BUP-XR increased from 6,721 units in the second half of 2019 (H2'19) to 12,925 in the first half of 2020 (H1'20). OHS distribution increased from H2'19 to H1'20 in every subtype but was primarily driven by IDN distribution growth. IDNs accounted for 73% of total units in H2'19 and continued to grow in H1'20. In H1'20, IDNs accounted for 78%, VHA for 12%, CJS for 6%, and IHS for 4%. IDN distribution for BUP-XR increased from 4,911 to 10,100 units, showing the highest growth rate of 106% within all OHS subtypes. The states with the highest total BUP-XR distribution over the 12-month period were Massachusetts (4,534), Pennsylvania (3,773), and California (1,866). Conclusions Overall distribution of BUP-XR, as a treatment option for OUD, is increasing; however, access to MOUD varies greatly across OHS subtypes and geography. Identifying and overcoming barriers to appropriate MOUD use is critical in addressing the opioid crisis.
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Affiliation(s)
- William Mullen
- Indivior, Inc., Richmond, VA, USA
- Corresponding author at: Associate Director for Real World Evidence, Indivior, Inc. 10710 Midlothian Turnpike, North Chesterfield, Virginia, USA.
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