Food and Drug Administration approval of sustained-release buprenorphine for treatment of opioid dependence: realizing its potential

Tinkering with care: Implementing extended-release buprenorphine depot treatment for opioid dependence

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.

Patients' goals when initiating long-acting injectable buprenorphine treatment for opioid use disorder: findings from a longitudinal qualitative study

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.

How do patients feel during the first 72 h after initiating long-acting injectable buprenorphine? An embodied qualitative analysis

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.

Perception of a New Prolonged-Release Buprenorphine Formulation in Patients with Opioid Use Disorder: The PREDEPO Study

AIM

The aim of the study was to assess the acceptance of patients with opioid use disorder (OUD) to switching their opioid dependence treatment (ODT) for a prolonged-release buprenorphine (PRB) injection according to their prior ODT (buprenorphine/naloxone [B/N] or methadone).

METHODS

This was an observational, retrospective/cross-sectional, multicentre study of adult patients diagnosed with OUD on ODT. Data collected from diaries were analysed to know their interest and opinion on PRB. Questions with fixed response options were included, and several Likert scales were used.

RESULTS

A total of 98 patients were enrolled (B/N: 50.0%, methadone: 50.0%). The mean age was 46.9 ± 8.43 years and 79.6% were males. PRB was similarly perceived by both groups in most variables analysed, receiving a mean score of 7.2/10 (B/N: 7.4, methadone: 7.0; p = 0.520), and approximately 65% of patients said they were willing to switch to PRB (B/N: 63.3%, methadone: 65.3%; p = 0.833). Of these, a higher percentage in the B/N group considered that switching would be easy/very easy (B/N: 90.3%, methadone: 46.9%; p < 0.001) and that they would start PRB when available (B/N: 64.5%, methadone: 34.3%; p = 0.005). More than 90% would prefer the monthly injection (B/N: 93.6%, methadone: 100%; p = 0.514). One-third of patients in both groups were unsure/would not switch their ODT to PRB (B/N: 36.7%, methadone: 34.7%; p = 0.833). The main reason was administration by injection.

CONCLUSION

Two-thirds of patients would switch their treatment for PRB, and most patients on B/N considered that switching would be easy. PRB could be a suitable alternative for OUD management.

Innovations in efforts to expand treatment for opioid use disorder

Fewer than 20% of Americans with opioid use disorder receive empirically-supported treatment. There is a critical need for innovative approaches to support expansion of evidence-based opioid treatment, particularly in rural geographic areas so impacted by the current opioid public health crisis. Doing so will require more diverse pathways into treatment, novel pharmacological tools, improved integration and efficiency among treatment modalities, and harm reduction when treatment is not available. In this invited commentary, we review exciting recent efforts to accomplish these aims as well as offer additional considerations for future clinical and research efforts to increase the availability of treatment for opioid use disorder.

Opioid users' willingness to receive prolonged-release buprenorphine depot injections for opioid use disorder

AIMS

Prolonged-release implantable and depot injection formulations of buprenorphine are very recent developments in the treatment of opioid use disorder. Such formulations remove the need for daily dosing and provide patients with sustained concentrations of buprenorphine over a period of weeks or months. We explored opioid users' personal willingness to receive prolonged-release buprenorphine depot injections and factors influencing their interest.

METHODS

The study took place in London during 2018, before depot buprenorphine was licensed for use in Europe. Thirty-six face-to-face, semi-structured qualitative interviews were conducted with people who were: i) using heroin daily and not receiving any treatment for opioid use (n = 12); or ii) prescribed daily oral buprenorphine (n = 12); or iii) prescribed daily oral methadone (n = 12). Participants were asked about their willingness to receive depot buprenorphine and were encouraged to discuss factors that might alter their opinions. Interview data were analysed following the stages of Iterative Categorization.

FINDINGS

Participants expressed a high level of willingness to receive depot buprenorphine. Their views were influenced both positively and negatively by six key features of depot buprenorphine: i) reduced contact with pharmacies and drug treatment services; ii) impact on illicit drug use and recovery; iii) the perceived effectiveness of depot buprenorphine; iv) the duration and dosage of depot buprenorphine injections; v) clinical administration of the depot buprenorphine injection; and vi) potential for side effects associated with the depot buprenorphine injection.

CONCLUSIONS

Willingness to receive a given medication is complex, individual and changeable. Opioid users seem likely to welcome greater choice and flexibility in respect of opioid agonist medications and appear more likely to accept and adhere to depot buprenorphine if it enables them to reduce their illicit drug use and facilitates their recovery. Research is now needed to assess whether patients' reported willingness to receive depot buprenorphine translates into actual uptake and adherence.

Prevention of Opioid Abuse and Treatment of Opioid Addiction: Current Status and Future Possibilities

Prescription opioid medications have seen a dramatic rise in misuse and abuse, leading regulators and scientists to develop policies and abuse-deterrent technologies to combat the current opioid epidemic. These abuse-deterrent formulations (ADFs) are intended to deter physical and chemical tampering of opioid-based products, while still providing safe and effective delivery for therapeutic purposes. Even though formulations with varying abuse-deterrent technologies have been approved, questions remain about their effectiveness. While these formulations provide a single means to combat the epidemic, a greater emphasis should be placed on formulations for treatment of addiction and overdose to help those struggling with opioid dependence. This article analyzes various ADFs currently in clinical use and explores potential novel systems for treatment of addiction and prevention of overdose.

Depot buprenorphine injections for opioid use disorder: Patient information needs and preferences

Introduction and Aims

There has been significant recent investment in new medications for opioid use disorder, including buprenorphine depot injections. Patients and professionals need good quality, independent information on medications to help them make informed treatment decisions. This paper aims to understand patients’ information needs and preferences in relation to buprenorphine depot injections.

Design and Methods

Semi‐structured qualitative interviews were conducted with 36 people using opioids (26 men, 10 women; 24–63 years). Twelve participants were currently prescribed daily oral methadone; 12 were currently prescribed daily oral buprenorphine; and 12 were using heroin and not in treatment. Interviews were transcribed, coded and analysed via Iterative Categorisation.

Results

Participants asked many questions about depot buprenorphine injections. These related to: (i) medication purpose and availability; (ii) pharmacology; (iii) evidence base and effectiveness; (iv) safety and side effects; (v) administration and dosing; and (vi) reducing and ending treatment. Additionally, participants expressed their information preferences in terms of (i) ‘format’ and (ii) ‘source’. Specifically, they wanted printed, verbal and electronic materials provided by people in authority, particularly patients who had already had the medication.

Discussion and Conclusions

All potential patients should be offered accessible information on depot buprenorphine to enable them to consider their options and participate meaningfully in treatment decision making. We recommend that further qualitative research is undertaken to produce informative video material that describes patient experiences of receiving depot buprenorphine. This should help to balance biomedical knowledge with lay knowledge, so facilitating more informed discussions when decisions about depot buprenorphine treatment are made.

Prolonged-release opioid agonist therapy: qualitative study exploring patients' views of 1-week, 1-month, and 6-month buprenorphine formulations

Background

Options for opioid agonist therapy (OAT) are expanding with the development of prolonged-release (also known as extended-release) 1-week, 1-month, and 6-month formulations of buprenorphine. There is an assumption that patients will welcome these new treatments and medication adherence will correspondingly increase. However, there has been little research exploring patients’ views of prolonged-release buprenorphine. This paper aims to understand which durations patients prefer and why, and to consider the findings with reference to the development of future OAT products.

Methods

Data were generated as part of a qualitative interview study. Fieldwork was conducted in London, UK, during 2018 (before any prolonged-release OAT formulations were licensed in Europe). Participants (n = 36) were taking daily oral OAT (methadone or buprenorphine) or using heroin daily without OAT. They included 26 men and 10 women, aged 24–63 years. All were asked for their views on weekly, monthly, and six-monthly duration buprenorphine. Responses were audio-recorded, transcribed, and analyzed by Iterative Categorization.

Results

Participants generally stated that having buprenorphine of different prolonged durations was positive. They tended to believe that ‘longer’ prolonged-release formulations would be beneficial for patients who wanted to avoid thinking about drugs and drug-using associates, wished to evade the stigma of substance use, and desired ‘normality’ and ‘recovery.’ In contrast, participants favored ‘shorter’ prolonged-release formulations for patients who are new to OAT, worried about the safety and reliability/effectiveness of OAT, want a ‘break’ from street opioids, and need contact with services to monitor/support them. Participants indicated that transitioning between OAT medications of different duration would be a very individual process. Some also linked prolonged-release OAT duration to political, philosophical, and ethical issues, such as patient coercion and mental capability.

Conclusions

Medication duration is an important but complex feature of prolonged-release buprenorphine, with patients’ views and preferences likely to be influenced by a wide range of factors. We need further qualitative research to explore the experiences of people who have actually used prolonged-release OAT. Meanwhile, drug developers should continue to build flexibility and choice into OAT products to ensure that future treatment is acceptable to patients and able to accommodate their diverse individual needs.

Factors influencing recruitment to a randomised placebo-controlled trial of oral naltrexone and extended release implant naltrexone: Qualitative study

AIMS

To understand the influences on recruitment to the Naltrexone Enhanced Addiction Treatment (NEAT) study, a randomised placebo-controlled trial of extended-release naltrexone (XR-NTX) implants for opioid use disorder (OUD), to learn lessons for the design and conduct of similar future research.

METHODS

29 face-to-face, semi-structured qualitative interviews were conducted with patients recruited to NEAT (n = 6), patients not recruited (n = 11), researchers who designed the trial (n = 5), and staff who delivered the trial (n = 7). The social marketing mix was used as a framework to guide the data analyses.

RESULTS

Dimensions of the 7Ps of the social marketing mix - product, price, place, promotion, physical environment, people, and processes all influenced recruitment to the NEAT trial. Among other things, the potential to receive a naltrexone implant (product); the provision of transport passes and shopping vouchers (price); clear verbal explanations (promotion); familiarity of the trial setting (physical environment); and approachable, friendly and informative trial delivery staff (people) positively influenced recruitment. Whereas, wanting a less medical approach to recovery (product); the perceived time, physical, and psychological costs of taking part (price); service ideological opposition to naltrexone in recovery (place); inaccessible written information (promotion); the location and nature of the trial setting (physical environment); a lack of knowledge about implants (people); and the blind allocation and potential of placebo (processes) deterred people from joining the trial.

CONCLUSIONS

Qualitative research informed by the social marketing mix as an analytical framework yielded detailed insights into understanding the factors and circumstances that influenced recruitment to the NEAT trial. Our findings have implications for the planning and implementation of future addiction trials, especially trials of extended-release formulations.

Implants and depot injections for treating opioid dependence: Qualitative study of people who use or have used heroin

BACKGROUND

Long-acting opioid pharmacotherapy (OPT) is presumed to offer benefits over more conventional OPT formulations. This paper analyzes the views and experiences of people who use or have used heroin in order to explore two novel systems for delivering long-acting OPT: implants and depot injections. New materialism theorizing is used to interpret and frame the findings.

METHODS

Qualitative data were generated via seven focus groups conducted during 2017 in London, UK. Participants (n = 44; 28 men and 16 women; ages 33-66 years) had all received OPT. Focus group discussions covered real and potential OPT delivery systems. All participant data relating to implants and depot injections were coded using MAXQDA software and analysed inductively via Iterative Categorisation.

FINDINGS

Participants discussed implants and depot injections in terms of interacting physical, psychological and social factors: dose stability; OPT administration; stopping treatment; co-presence of an antagonist; breaking rituals and habits; reduced choice and control; feeling normal; information needs; getting on with everyday life; and social interaction. Participants identified both benefits and concerns, and variable needs and preferences, with respect to each delivery system.

CONCLUSIONS

Implants and depot injections are not 'fixed' medications that can be administered to people to achieve pre-determined treatment aims. Rather, they are complex 'assemblages' with uncertain outcomes. Furthermore, they are themselves part of wider interactive 'assemblages'. Drug developers and treatment providers need to understand this complexity in order to target long-acting OPT at people most likely to benefit from it, and to reduce any unintended negative consequences.

Improving recruitment to pharmacological trials for illicit opioid use: findings from a qualitative focus group study

AIM

To explore potential study participants' views on willingness to join clinical trials of pharmacological interventions for illicit opioid use to inform and improve future recruitment strategies.

DESIGN

Qualitative focus group study [six groups: oral methadone (two groups); buprenorphine tablets (two groups); injectable opioid agonist treatment (one group); and former opioid agonist treatment (one group)].

SETTINGS

Drug and alcohol services and a peer support recovery service (London, UK).

PARTICIPANTS

Forty people with experience of opioid agonist treatment for heroin dependence (26 males, 14 females; aged 33-66 years).

MEASUREMENTS

Data collection was facilitated by a topic guide that explored willingness to enrol in clinical pharmacological trials. Groups were audio-recorded and transcribed. Transcribed data were analysed inductively via Iterative Categorization.

FINDINGS

Participants' willingness to join pharmacological trials of medications for opioid dependence was affected by factors relating to study burden, study drug, study design, study population and study relationships. Participants worried that the trial drug might be worse than, or interfere with, their current treatment. They also misunderstood aspects of trial design despite the researchers' explanations.

CONCLUSIONS

Recruitment of participants for clinical trials of pharmacological interventions for illicit opioid use could be improved if researchers became better at explaining clinical trials to potential participants, dispelling misconceptions about trials and increasing trust in the research process and research establishment. A checklist of issues to consider when designing pharmacological trials for illicit opioid use is proposed.

Controlling release from 3D printed medical devices using CLIP and drug-loaded liquid resins

Mass customization along with the ability to generate designs using medical imaging data makes 3D printing an attractive method for the fabrication of patient-tailored drug and medical devices. Herein we describe the application of Continuous Liquid Interface Production (CLIP) as a method to fabricate biocompatible and drug-loaded devices with controlled release properties, using liquid resins containing active pharmaceutical ingredients (API). In this work, we characterize how the release kinetics of a model small molecule, rhodamine B-base (RhB), are affected by device geometry, network crosslink density, and the polymer composition of polycaprolactone- and poly (ethylene glycol)-based networks. To demonstrate the applicability of using API-loaded liquid resins with CLIP, the UV stability was evaluated for a panel of clinically-relevant small molecule drugs. Finally, select formulations were tested for biocompatibility, degradation and encapsulation of docetaxel (DTXL) and dexamethasone-acetate (DexAc). Formulations were shown to be biocompatible over the course of 175 days of in vitro degradation and the clinically-relevant drugs could be encapsulated and released in a controlled fashion. This study reveals the potential of the CLIP manufacturing platform to serve as a method for the fabrication of patient-specific medical and drug-delivery devices for personalized medicine.

Perspectives on the Pharmacological Treatment of Heroin Addiction

Opioids are very addictive drugs because of their powerful effects on reward and pain pathways in the brain. Opioid addiction is currently a worldwide problem and injecting heroin presents serious health risks including death from overdose. The increase in the nonmedical use of prescription opioids and the increase in overdose deaths are worrying trends in North America. There is therefore an increasing need for access to effective treatments. The 2 major drug treatments, methadone and buprenorphine, have proven efficacy but are not necessarily administered in the most effective doses or under optimum conditions. Alternative approaches such as slow-release oral morphine, tincture of opium, and the use of the opioid antagonist naltrexone to maintain abstinence are used seemingly effectively in some countries but have yet to be fully evaluated in randomized controlled trials. Heroin-assisted treatment has proven to be a valuable and effective treatment when administered in specialized clinics but is only appropriate for those who have failed to improve on optimal methadone or buprenorphine maintenance. Recent innovations and substitution treatment as an alternative to incarceration are described. Drug treatment of opioid addiction is most effective when administered as part of a therapeutic program as demonstrated in the initial methadone evaluations and the more recent trials with heroin-assisted treatment.

Medications for substance use disorders (SUD): emerging approaches

INTRODUCTION

Substance use disorders are a group of chronic relapsing disorders of the brain, which have massive public health and societal impact. In some disorders (e.g., heroin/prescription opioid addictions) approved medications have a major long-term benefit. For other substances (e.g., cocaine, amphetamines and cannabis) there are no approved medications, and for alcohol there are approved treatments, which are not in wide usage. Approved treatments for tobacco use disorders are available, and novel medications are also under study. Areas covered: Medication-based approaches which are in advanced preclinical stages, or which have reached proof-of concept clinical laboratory studies, as well as clinical trials. Expert opinion: Current challenges involve optimizing translation between preclinical and clinical development, and between clinical laboratory studies to therapeutic clinical trials. Comorbidities including depression or anxiety are challenges for study design and analysis. Improved pharmacogenomics, biomarker and phenotyping approaches are areas of interest. Pharmacological mechanisms currently under investigation include modulation of glutamatergic, GABA, vasopressin and κ-receptor function, as well as inhibition of monoamine re-uptake. Other factors that affect potential market size for emerging medications include stigma, availability of treatment settings, adoption by clinicians, and the prevalence of persons with SUD who are not actively treatment-seeking.