Volume 214 - Issue 11
Buprenorphine: extended‐release formulations “a game changer”!
Author: Katerina Lagios
Med J Aust 2021; 214 (11): 534-534.e1. || doi: 10.5694/mja2.51098
Published online: 21 June 2021
Published online: 21 June 2021
To the Editor: There is a new player in the treatment of opioid use disorder: extended‐release depot buprenorphine. This has been hailed “a game changer”1 and has proven to be of great benefit, particularly during the current coronavirus disease 2019 (COVID‐19) pandemic. Depot buprenorphine has an impact on presentations to hospital and health services, meaning that all clinicians must be familiar with the advantages and disadvantages (Box) as well as the formulations.
Opioid use disorder is a complex, chronic, relapsing health condition that requires lengthy management and is over‐represented in incarcerated people. Opioid treatment successfully reduces illicit use, overdose deaths, and costs. In Australia, there are opioid treatment programs for incarcerated persons, improving individual and community wellbeing and social functioning following release.
However, until recently, the treatment perpetuated a daily drug pattern and risks, such as diversion to others, injecting opioid treatments, overdose risks and violent behaviour.2
What changed the game and model of care in Australia is the development of extended‐release depot buprenorphine. The Australian game has two products: one is available as weekly and monthly injection options and the other as a monthly injection.
Depot buprenorphine is a subcutaneous injection and must be administered by a health care professional, as inadvertent injection into other structures forms a depot gel that will not provide slow release of the medication and depot gels in a vein may cause serious, life‐threatening health problems.3
Weekly or monthly doses of depot buprenorphine are provided following stabilisation using sublingual buprenorphine, most often for 7 days, and may be started the day after the last daily sublingual buprenorphine. Dose conversion tables exist to match depot buprenorphine to the sublingual buprenorphine dose. Steady state equilibrium is achieved after three to four doses.3
Hospital and health service clinicians must be aware that all buprenorphine formulations complicate routine opioid analgesia for acute pain management, and consideration of other non‐opioid‐adjuvant analgesics is needed (Box).3
Uptake of depot buprenorphine has been welcomed by patients, the community and correctional programs, with many who have transitioned reporting positive outcomes, including reduction in cravings, anxiety, improved attitude, relationships, and general mood.4
The timing of this game changing depot buprenorphine has enabled remote health care and ongoing availability of opioid therapy in the context of the COVID‐19 pandemic.5
Box – Advantages and disadvantages of depot buprenorphine
Advantages of depot buprenorphine:
- it provides greater convenience and does not require attendance for daily dosing
- it reduces the treatment cost for clients and service providers
- it has less risk of diversion and non-medical use of the medication
- it has greater medication adherence and enhanced treatment outcomes
- it opens opportunities for normal life and to consider employment, study and travel
- it removes risks related to takeaway opioid treatment doses
- it reduces stigma and discrimination and has a positive impact on the way that people with opioid use problems are perceived
Disadvantages of depot buprenorphine:
- it complicates routine opioid analgesia in the management of severe acute pain:
- it may require the use of higher doses of traditional opioids such as morphine; and
- it may require the use of a mu opioid receptor super agonist such as fentanyl and/or the use of non-opioid analgesic approaches (eg, ketamine infusions or regional analgesia)
- it provides reduced patient health care, social interactions and support opportunities
- it results in a loss of control over how the patient manages their dose (especially takeaways)
Competing interests
No relevant disclosures.
References
- Hendrie D. Advocates hail “game changing” PBS listing of buprenorphine. News GP, Royal Australian College of General Practitioners, 2019. https://www1.racgp.org.au/newsgp/clinical/advocates-hail-game-changing-pbs-listing-of-long-a (viewed Nov 2020).
- Gowing L, Ali R, Dunlop A, Farrell M, Lintzeris N. National guidelines for medication‐assisted treatment of opioid dependence 2014. Commonwealth of Australia, 2014. https://www.health.gov.au/sites/default/files/national-guidelines-for-medication-assisted-treatment-of-opioid-dependence.pdf (viewed Nov 2020).
- Lintzeris N, Dunlop A, Masters M. Clinical guidelines for use of depot buprenorphine (Buvidal and Sublocade) in the treatment of opioid dependence. NSW Health, 2019. https://www.health.nsw.gov.au/aod/Publications/full-depot-bupe-interim-gl.pdf (viewed Nov 2020).
- Frost M, Bailey GL, Lintzeris N, et al. Long‐term safety of a weekly and monthly subcutaneous buprenorphine depot (CAM2038) in the treatment of adult out‐patients with opioid use disorder. Addiction 2019; 114: 1416–1426.
- Lintzeris N, Hayes V, Arunogiri S. Interim guidance for the delivery of medication assisted treatment of opioid dependence in response to COVID‐19: a national response. Royal Australasian College of Physicians, 2020. https://www.racp.edu.au/docs/default-source/news-and-events/covid-19/interim-guidance-delivery-of-medication-assisted-treatment-of-opiod-dependence-covid-19.pdf (viewed Nov 2020).