An injectable-only buprenorphine initiation protocol that doesn’t require cessation of fentanyl had a 75% rate of completion at an urban outreach clinic, according to a study appearing in JAMA Network Open.
“Our findings add to the sparse literature on rates of successful completion of existing and novel buprenorphine starting protocols outside of acute care settings for individuals using fentanyl,” wrote Richard C. Waters, M.D., M.Sc., of the Downtown Emergency Service Center in Seattle, and colleagues. “In the largest study of overlapping sublingual buprenorphine starts (also called low-dose initiations) in outpatient settings, 35% of individuals completed the protocol, with 22% retained at 28 days.”
Waters and colleagues recruited 95 adults who voluntarily sought treatment for moderate to severe opioid use disorder (OUD) with active fentanyl use at a treatment program in downtown Seattle; 79% of the adults were homeless or had a history of chronic homelessness. The patients agreed to try an investigational three-day buprenorphine initiation protocol involving only three overlapping injections, with no required prior sublingual dosing of the medication or cessation of fentanyl required. On day one, patients received a weekly 8 mg injection; on day two, a weekly 16 mg injection; and on day three, the choice of a monthly 128 mg or 300 mg injection.
Of the 95 patients included, 90% initiated the protocol and 75% eventually completed the protocol by receiving at least one monthly injection; the vast majority of completing participants (94%) chose the higher monthly dose (300 mg) injection option. In addition, 72% of participants who initiated the treatment were retained, defined as receiving a second monthly long-acting buprenorphine injection. Researchers found that an individual’s housing status did not impact their odds of completing the initiation protocol.
The researchers noted that their care program was low-threshold (requiring minimal demands on patients) and outreach-focused, which likely contributed to the high retention; thus, their results may not generalize to patients in other care settings. The study also lacked standardized assessments of withdrawal symptoms after each injection, some of which were severe.
“Future research should describe the patient experience and quantify the prevalence and magnitude of patient-reported opioid withdrawal symptoms experienced during this protocol,” the researchers wrote.
For more information, see the Psychiatric News story “Clinicians Find Low-Dose Regimens Ease Initiation of Buprenorphine.”
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