Tuesday, July 9, 2024

Long-Acting Buprenorphine May Help Patients Initiate Treatment Without Withdrawal

Most patients with opioid use disorder (OUD) and mild withdrawal symptoms can initiate buprenorphine using a 7-day injection without precipitating withdrawal symptoms, according to a study issued in JAMA Network Open.

“To date, there is little evidence for rapid strategies to initiate buprenorphine without the prerequisite withdrawal,” wrote lead author Gail D’Onofrio, M.D., at Yale School of Medicine and colleagues. “Thus, patients are often instructed to initiate buprenorphine on their own after a brief education or are discharged without medication treatment, leaving them at risk for overdose.”

D’Onofrio and colleagues recruited 100 patients at emergency departments (ED) who had screened positive for moderate to severe OUD; all were experiencing minimal to mild withdrawal as measured on the Clinical Opioid Withdrawal Scale (COWS), with 38 scoring 0-3 and 62 scoring 4-7. All received a 7-day injectable 24 mg formulation of extended-release buprenorphine, CAM2038, which is equivalent to 16 mg of buprenorphine daily.

Participants were monitored in the ED for four hours and referred to community-based programs or clinicians for ongoing OUD treatment upon discharge. Over the following week, they provided daily phone and text assessments on their opioid use, cravings, injection pain or other side effects, and engagement with treatment.

Each day, between 33% and 43% of patients reported no cravings, and between 78% and 85% reported no use of opioids. Overall, 60% of participants did not use opioids in the week after buprenorphine administration, and there were also no reported incidences of overdoses. In addition, 73% of patients engaged in OUD treatment within seven days of the injection. Participants rated the improved privacy and not requiring daily medication as extremely important advantages of the long-acting formulation.

Within four hours of receiving the injection, just 10 of the 100 patients experienced a 5-point or greater increase in COWS scores and of those, seven participants transitioned to moderate or greater withdrawal (COWS score of 13 or higher). Participants who had baseline COWS scores of 0 to 3 were more likely to experience significantly increasing withdrawal, so researchers said further study is needed to assess the criteria for using rapid buprenorphine initiation in this subgroup.

“The opportunity to initiate buprenorphine in patients without having to first experience prolonged withdrawal has many clear benefits and could substantially increase the number of patients with OUD able to initiate buprenorphine upon ED presentation,” researchers wrote. “This finding may have a significant public health impact in light of the continued increase in opioid deaths in 2023 driven primarily from fentanyl and the heightened risk of overdose death without medication treatment.”

For more information, see the Psychiatric News article, “OUD Overdose, Suicide Risk in Veterans Four Times Higher Without Buprenorphine.”

(Image: Getty Images/iStock/Kobus Louw)

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