Can monthly injections curb addiction? These experts say yes.

OAKLAND, Calif. – Dr. Andrew Herring has a clear goal in every appointment with patients seeking medication for an opioid use disorder: to persuade them to receive an injection of sustained-release buprenorphine.

At his addiction clinic at Highland Hospital, a bustling public facility in the heart of Oakland, Herring promotes giving buprenorphine a shot in the belly to provide a month of addiction treatment rather than prescribing oral versions that should be taken daily. For him, the long-acting protection of injections is a “game changer” and may be his only chance to help a vulnerable patient at risk of overdose.

“At any time, they’re just a ball that’s going to go,” Herring said. “You might just have that one interaction. And the question is, how powerful can you make it?”

In California, where overdose deaths have been rising for years, addiction experts say there’s great potential in giving a month’s worth of anti-addiction medication, especially for people who are homeless or struggling with other forms of instability. Yet, despite its promise, the use of injectable buprenorphine remains quite limited, especially compared to other forms of addiction medication. Researchers have not yet published studies comparing different ways of giving buprenorphine.

Buprenorphine, one of three drugs approved in the United States to treat opioid use disorder, works by binding to opioid receptors in the brain and reducing cravings and withdrawal symptoms. And because it occupies these receptor sites, buprenorphine prevents other opioids from binding and ensures that if a patient takes a high dose of a drug like heroin or fentanyl, they are less likely to overdose. Patients often stay on buprenorphine for years.

If Herring prescribes a supply of buprenorphine in tablet or film form that is placed under the tongue, the patient must commit to taking the drug at least once a day, and many drop out of treatment. He said this is especially true for his homeless patients and those who also use methamphetamine.

“It’s like a religious thing — you have to wake up every morning and repeat your vows,” Herring said. “In reality, there are many people who deserve treatment who cannot meet this requirement.”

Oral forms of buprenorphine have been available to treat addiction since 2002 and can be purchased as a generic for less than $100 per month. Injectable buprenorphine, sold under the brand name Sublocade, received FDA approval in 2017. Its list price is high by $1,829.05 for a monthly injection. Drugmaker Indivior reported $244 million in Sublocade’s revenue last year alone, with a company goal of eventually achieving $1 billion in annual sales. No generic or competitive version of the drug is available.

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Most patients won’t pay full price, Indivior says, because most health insurance plans cover the drug. Doctors, however, say the high cost can be a barrier for patients with private health insurance plans, which sometimes resist covering the drugs. Medi-Cal, California’s health insurance program for low-income individuals, covers Sublocade without prior approval, making the treatment accessible to the majority of Herring’s patients.

Yet, according to addiction experts, the use of Sublocade remains limited due to the regulatory hurdles needed to dispense it.

Providers must register with the United States Drug Enforcement Administration and obtain a waiver to prescribe buprenorphine, as it is considered a controlled substance. In addition, clinics must complete a FDA Safety Certification Program to dispense the medicine. And Sublocade can only be ordered through a specialty pharmacy, which must also pass the FDA program.

“In many hospitals, this will either mean a delay in getting this medicine on our shelves or simply a withdrawal,” said Dr Rais Vohra, regional director of the California Bridge Systema publicly funded program that helps hospitals provide treatment for substance use disorders, including the Herring Clinic.

Vohra said the Fresno Community Regional Medical Center, where he works as an emergency physician, is still reviewing documentation requirements to see if the hospital’s pharmacy can dispense the drugs, which would make it one of the few Central Valley suppliers to do so.

Oral buprenorphine, on the other hand, is a simple prescription that most local pharmacies keep in stock.

“All the hurdles that clinicians and patients have to jump through to get this drug is crazy. We don’t do it for any other disease,” said Dr. Hannah Snyder, who runs the addiction clinic at Zuckerberg General Hospital in San Francisco, across the bay.

Several clinicians have noted that access remains a problem even with oral forms of buprenorphine. Despite a cascade of studies proving the effectiveness of drug treatment, many patients across the country struggle to find a provider willing to prescribe buprenorphine in any form – especially in communities of color.

“The more important question is not whether long-acting injectable bupe is a better solution than sublingual buprenorphine for opioid use disorder,” said Dr. Michael Ostacher, professor at the Stanford University School of Medicine, which compares injectable and oral versions of buprenorphine through Veterans Affairs. “The biggest question is how do we increase access to treatment for all people who need [the medication].”

Angela Griffiths is one of the patients who say Sublocade has changed their lives. Griffiths, 41, of San Francisco, used heroin for 18 years. When she was pregnant with her daughter in 2016, doctors put her on methadone, which made her “miserable”. Three years ago, she said, she switched to buprenorphine movies, but carrying the tapes around with her still made her feel tied to her addiction.

“The ritual of taking something every day plays something in your mind,” Griffiths said.

When doctors at the SF General Clinic switched her to monthly injections of Sublocade, she described the change as “amazing”.

“I no longer search my drawer for a solution,” she said. “I have the freedom to wake up and start my day any way I want, whether that’s going out on the patio and having a cup of coffee or snuggling up with my daughter in bed for a bit longer. It’s here; I have nothing to take. »

In states where Medicaid plans may still require pre-approval, Sublocade waits can stretch for months. Across the border, at the Northern Nevada Hopes Clinic in Reno, Nevada, for example, Dr. Taylor Tomlinson said she tells patients that between battles for coverage and pharmacy delays, they may have to wait two months for an injection.

“I will always offer it to a patient who I think would be a good candidate, but in the time they have to wait they are interested in other things,” Tomlinson said. “It creates a barrier to care.”

California’s Medicaid program does not require prior authorization, but providing Sublocade remains a challenge. At the California Bridge Network-supported Placerville clinic, director Dr. Juliet La Mers said a quarter of her patients on buprenorphine receive injections. However, they often wait two weeks before Sublocade arrives from the specialist pharmacy.

Herring was able to reduce some of this bureaucracy in his Oakland clinic by working with Highland Pharmacy to stock and distribute Sublocade. As soon as a patient accepts an injection, Herring simply calls the pharmacy down the hall and administers it on the spot.

Herring sees the urgency — and the opportunity — to increase the use of injectable buprenorphine as fentanyl use increases throughout California. For years, the deadly synthetic opioid has been concentrated primarily on the East Coast; in 2018, 88% of deaths from synthetic opioids occurred in all 28 states east of the Mississippi River. But more recently, fentanyl has started to seep into western states. From 2018 to 2020, deaths from fentanyl overdoses in California increased fivefold, according to state data.

“Nobody understands what they’re dealing with,” Herring said of the potency of fentanyl. “This is when our biggest deaths are going to happen.”

KHN (Kaiser Health News) is a national newsroom that produces in-depth journalism on health issues. Along with policy analysis and polling, KHN is one of the three main operating programs of KFF (Kaiser Family Foundation). KFF is an endowed non-profit organization providing information on health issues to the nation.