Perceptions of extended-release buprenorphine injections for opioid use disorder among people who regularly use opioids in Australia

Optimizing retention strategies for opioid use disorder pharmacotherapy: The retention phase of the CTN-0100 trial (RDD)

INTRODUCTION AND BACKGROUND

The three medications approved to address OUD are effective in decreasing opioid use and morbidity and mortality; however, their utility is limited by high rates of dropout from treatment. The CTN-0100 trial will develop an evidence base for strategies to improve retention on buprenorphine and extended-release naltrexone.

RESEARCH DESIGN AND METHODS

The National Drug Abuse Treatment Clinical Trials Network (CTN) study CTN-0100, "Optimizing Retention, Duration and Discontinuation Strategies for Opioid Use Disorder Pharmacotherapy" (RDD), is a multicenter, randomized, non-blinded trial enrolling more than a thousand patients from 18 community-based substance use disorder treatment programs. Participants are adult volunteers seeking to initiate medication treatment for OUD (MOUD). Individuals choose between buprenorphine or extended-release injectable naltrexone. The trial randomizes participants choosing buprenorphine, in a 3 × 2 factorial design, to a medication condition (standard-dose sublingual buprenorphine, high-dose sublingual buprenorphine, or extended-release injectable buprenorphine) and to a behavioral condition (Medical Management or Medical Management plus a digital therapeutic (smartphone) app). Individuals choosing extended-release naltrexone are randomized only to a behavioral condition. Participants receive study medication for 74 weeks and are then followed for a further 24 weeks. The primary outcome is successful retention on MOUD at 26 weeks (six months), with 50- and 74-week retention among the secondary outcomes.

DISCUSSION/CONCLUSION

Dropout from treatment is a major barrier to the effectiveness of MOUD. The CTN-0100 study will determine whether strategies such as high dose sublingual or extended-release buprenorphine, or an app-based behavioral intervention improve retention on MOUD.

CLINICALTRIALS

gov Identifier: NCT04464980.

Investigating outcomes in a substance use treatment provider: a cross-sectional comparison of long-acting injectable buprenorphine and oral medication for opioid use disorder

OBJECTIVES

Advances in the treatment of opioid use disorder (OUD) have seen the development of long-acting injectable opioid substitutes which could improve outcomes for people with OUD. However, comparative quantitative analysis of individual outcomes is lacking. The present study sought to investigate factors associated with prescribing long-acting injectable buprenorphine (LAIB), and changes in outcome variables compared with oral medication for OUD.

DESIGN

Cross-sectional retrospective analysis of electronic health records.

SETTING

Community substance use treatment service Via. Six sites shared their data between 15 August 2022 and 15 August 2023.

PARTICIPANTS

Anonymised data were extracted for 235 people receiving LAIB and 266 people receiving oral medication for OUD.

PRIMARY AND SECONDARY OUTCOMES

Prescribing data, sociodemographic information (age, sex, indices of multiple deprivation decile of individual's residence, primary and secondary substance, number of previous treatment episodes, employment and ethnicity) and treatment outcome profiles (substance use, physical and mental health, quality of life, employment) were extracted and analysed. To examine predictors of receiving LAIB (vs medication for OUD), we conducted logistic regression including the demographic predictors. Psychological health, physical health and quality of life scores were analysed using Welch's t-tests.

RESULTS

LAIB was associated with positive changes in quality of life between the first and last assessments. Demographic and situational factors were predictors of LAIB initiation, indicating the potential for increasing health inequalities in substance use treatment.

CONCLUSIONS

LAIB is associated with changes in quality of life over a 1-year period. Further research is needed to investigate the aetiology of improved well-being and outcomes over time.

Provider costs of treating opioid dependence with extended-release buprenorphine in Australia

INTRODUCTION

The costs of providing medication-assisted treatment for opioid dependence can determine its scale of provision. To provide estimates of the costs of extended-release buprenorphine (BUP-XR), we performed a bottom-up costing analysis of provider operational treatment costs.

METHODS

Data were collected in a single-arm open label trial of BUP-XR injections conducted in specialist public drug treatment services and primary care private practices in three Australian states (the CoLAB study). The unit costs of resources used for each activity were combined with quantities used at each participating facility to arrive at the average annual cost per client.

RESULTS

One hundred participants across the six health facility sites received monthly subcutaneous BUP-XR injections administered by a health-care practitioner. The average cost of providing 1 year of treatment per participant was $6656 ($6026-$8326). Screening cost (initial assessment and medical history) was $282 while monthly follow-up appointments cost $531 per client. The main cost driver was the monthly treatment costs accounting for 79% of the average annual client cost, with medication costs comprising 95% of this cost.

DISCUSSION AND CONCLUSION

With medication costs making up the largest proportion of treatment costs, treatment using BUP-XR has the potential to free up other health system resources, for example, staff time. The costs reported in this study can be used in an economic evaluation to estimate the net benefit or cost-effectiveness of BUP-XR especially when compared to other opioid agonist treatments.

"You might be nice, but where you take me, they're not gonna be": Preferences for field-based post-overdose interventions

INTRODUCTION

Emergency medical services (EMS) systems are piloting interventions to respond to overdoses with additional services such as leave-behind naloxone and medication for opioid use disorder, but little is known about the perspectives of people who use drugs (PWUD) on these interventions being delivered by EMS during an overdose response.

METHODS

The Consolidated Framework for Implementation Research guided the development of data collection tools, the analytic strategy and the organisation of results. A community engaged method was used which included both academically trained researchers and community trained researchers who are also PWUD. This study used semi-structured interviews to gather data from 13 PWUD in King County, Washington in June 2022. Data were analysed using thematic analysis.

RESULTS

The people interviewed for this study viewed EMS distribution of leave-behind naloxone and field-based buprenorphine favourably. They viewed EMS facilitation of hepatitis C virus and HIV testing in the field less favourably and were concerned about stigmas associated with those results. Additional themes emerged regarding: the need for different approaches to post-overdose care; the need for new services, including post-overdose trauma counselling and an alternative destination to the emergency department; and the harms of law enforcement presence at overdose responses.

DISCUSSION AND CONCLUSIONS

This study found strong support for leave-behind naloxone and field-initiated buprenorphine. Further training for EMS should include trauma-informed care and strategies to address burnout and increase compassion. Alternatives to the emergency department as a post-overdose destination are needed. These strategies should be considered by jurisdictions revising overdose response protocols.

Long-Acting Injectable Buprenorphine for Opioid Use Disorder: A Qualitative Analysis of Patients' Interpersonal Relationships during the First Year of Treatment

Introduction: Long-acting injectable buprenorphine (LAIB) is a new treatment for opioid use disorder. Drawing upon new materialism and the concept of social capital, this article provides a focused analysis of how LAIB affects, and is affected by, patients' relationships with other people. Methods: Data derive from a longitudinal qualitative study. Twenty-six people (18 males; 8 females) initiating LAIB were recruited from England and Wales (2020/2021) and interviewed up to six times each over a year (125 interviews in total). Interviews were audio-recorded, transcribed, and coded. Coded relationship data were summarized in Excel and analyzed via Iterative Categorization. Results: Core significant others who did not use substances offered participants important support with LAIB. Children and grandchildren provided motivation for LAIB, whilst other family relationships could be supportive and unsupportive. Participants wanted to avoid friends, peers and associates who might offer them substances, but valued sharing experiences with others in similar circumstances. Whilst some participants were unconcerned when treatment staff did not contact them, others were angry and upset. Those who did not continue LAIB or were lost from the study were more isolated at recruitment. Meanwhile, participants who remained on LAIB described increased sociability over time. Conclusions: Findings are consistent with ideas relating to new materialism (LAIB is part of an interacting network of material and non-material factors) and social capital (those with supportive relationships benefited more from LAIB). Interpersonal relationships need to be considered as part of routine care and should be reviewed with patients throughout the treatment journey.

The effectiveness of abstinence-based and harm reduction-based interventions in reducing problematic substance use in adults who are experiencing homelessness in high income countries: A systematic review and meta-analysis: A systematic review

Background

Homelessness is a traumatic experience, and can have a devastating effect on those experiencing it. People who are homeless often face significant barriers when accessing public services, and have often experienced adverse childhood events, extreme social disadvantage, physical, emotional and sexual abuse, neglect, low self-esteem, poor physical and mental health, and much lower life expectancy compared to the general population. Rates of problematic substance use are disproportionately high, with many using drugs and alcohol to deal with the stress of living on the street, to keep warm, or to block out memories of previous abuse or trauma. Substance dependency can also create barriers to successful transition to stable housing.

Objectives

To understand the effectiveness of different substance use interventions for adults experiencing homelessness.

Search Methods

The primary source of studies for was the 4th edition of the Homelessness Effectiveness Studies Evidence and Gaps Maps (EGM). Searches for the EGM were completed in September 2021. Other potential studies were identified through a call for grey evidence, hand-searching key journals, and unpacking relevant systematic reviews.

Selection Criteria

Eligible studies were impact evaluations that involved some comparison group. We included studies that tested the effectiveness of substance use interventions, and measured substance use outcomes, for adults experiencing homelessness in high income countries.

Data Collection and Analysis

Descriptive characteristics and statistical information in included studies were coded and checked by at least two members of the review team. Studies selected for the review were assessed for confidence in the findings. Standardised effect sizes were calculated and, if a study did not provide sufficient raw data for the calculation of an effect size, author(s) were contacted to obtain these data. We used random-effects meta-analysis and robust-variance estimation procedures to synthesise effect sizes. If a study included multiple effects, we carried out a critical assessment to determine (even if only theoretically) whether the effects are likely to be dependent. Where dependent effects were identified, we used robust variance estimation to determine whether we can account for these. Where effect sizes were converted from a binary to continuous measure (or vice versa), we undertook a sensitivity analysis by running an additional analysis with these studies omitted. We also assessed the sensitivity of results to inclusion of non-randomised studies and studies classified as low confidence in findings. All included an assessment of statistical heterogeneity. Finally, we undertook analysis to assess whether publication bias was likely to be a factor in our findings. For those studies that we were unable to include in meta-analysis, we have provided a narrative synthesis of the study and its findings.

Main Results

We included 48 individual papers covering 34 unique studies. The studies covered 15, 255 participants, with all but one of the studies being from the United States and Canada. Most papers were rated as low confidence (n = 25, or 52%). By far the most common reason for studies being rated as low confidence was high rates of attrition and/or differential attrition of study participants, that fell below the What Works Clearinghouse liberal attrition standard. Eleven of the included studies were rated as medium confidence and 12 studies as high confidence. The interventions included in our analysis were more effective in reducing substance use than treatment as usual, with an overall effect size of -0.11 SD (95% confidence interval [CI], -0.27, 0.05). There was substantial heterogeneity across studies, and the results were sensitive to the removal of low confidence studies (-0.21 SD, 95% CI [-0.59, 0.17] - 6 studies, 17 effect sizes), the removal of quasi-experimental studies (-0.14 SD, 95% CI [-0.30, 0.02] - 14 studies, 41 effect sizes) and the removal of studies where an effect size had been converted from a binary to a continuous outcome (-0.08 SD, 95% CI [-0.31, 0.15] - 10 studies, 31 effect sizes). This suggests that the findings are sensitive to the inclusion of lower quality studies, although unusually the average effect increases when we removed low confidence studies. The average effect for abstinence-based interventions compared to treatment-as-usual (TAU) service provision was -0.28 SD (95% CI, -0.65, 0.09) (6 studies, 15 effect sizes), and for harm reduction interventions compared to a TAU service provision is close to 0 at 0.03 SD (95% CI, -0.08, 0.14) (9 studies, 30 effect sizes). The confidence intervals for both estimates are wide and crossing zero. For both, the comparison groups are primarily abstinence-based, with the exception of two studies where the comparison group condition was unclear. We found that both Assertative Community Treatment and Intensive Case Management were no better than treatment as usual, with average effect on substance use of 0.03 SD, 95% CI [-0.07, 0.13] and -0.47 SD, 95% CI [-0.72, -0.21] 0.05 SD, 95% CI [-0.28, 0.39] respectively. These findings are consistent with wider research, and it is important to note that we only examined the effect on substance use outcomes (these interventions can be effective in terms of other outcomes). We found that CM interventions can be effective in reducing substance use compared to treatment as usual, with an average effect of -0.47 SD, 95% CI (-0.72, -0.21). All of these results need to be considered in light of the quality of the underlying evidence. There were six further interventions where we undertook narrative synthesis. These syntheses suggest that Group Work, Harm Reduction Psychotherapy, and Therapeutic Communities are effective in reducing substance use, with mixed results found for Motivational Interviewing and Talking Therapies (including Cognitive Behavioural Therapy). The narrative synthesis suggested that Residential Rehabilitation was no better than treatment as usual in terms of reducing substance use for our population of interest.

Authors' Conclusions

Although our analysis of harm reduction versus treatment as usual, abstinence versus treatment as usual, and harm reduction versus abstinence suggests that these different approaches make little real difference to the outcomes achieved in comparison to treatment as usual. The findings suggest that some individual interventions are more effective than others. The overall low quality of the primary studies suggests that further primary impact research could be beneficial.

Compared implementation of the long-acting buprenorphine treatment buvidal in four European countries

BACKGROUND

Buvidal is the only depot buprenorphine currently available in Europe. Buvidal offers a new treatment paradigm, which may require some adjustment in the national regulatory frameworks for opioid agonist treatments (OATs), as well as the national care systems.

RESEARCH DESIGN AND METHODS

Data on the national dissemination of Buvidal, types of populations treated, and the national regulatory framework and care organization system through which Buvidal has been implemented were compared between the UK, Finland, Spain, and France, using a qualitative survey.

RESULTS

In 2022, the proportion of people on OAT who received Buvidal was 2.1% in the UK, 60-65% in Finland, 1% in Spain, and 0.3% in France. In both Finland and the UK, the cost of the medication is covered by the national health system, whereas, in Spain and France, Buvidal is accessible only in specialized centers, which must carry its cost. Other national features may explain the gaps in Buvidal use, including the baseline level of OAT coverage, which was high in both France and Spain.

CONCLUSIONS

Important national discrepancies are found regarding Buvidal dissemination among people on OAT.

Predictive factors for acceptance of a long-acting opiate substitution treatment studied through social representations and internalized stigma

OBJECTIVES

Opioid use disorder is a public health problem worldwide with a treatment gap partially due to sociocultural representation and stigma. Taking the opportunity of an authorization to a subcutaneous (SC) injectable solution of buprenorphine, the first and only injectable treatment for opioid dependence available in France, we investigate potential obstacles to its implementation in France.

METHODS

This study aimed to define the factors predicting the acceptance of a new SC form of opiate substitution treatment (OST) by comparing the social representations using an adapted version of the Explanatory Model Interview Catalogue (EMIC) and the internalized stigma of intravenous drug injection using the Internalized Stigma of Mental Illness Inventory (ISMI) between participants receiving OST likely to accept the SC form or not. We also observed whether the fear of an opiate withdrawal syndrome could influence this choice.

RESULTS

Fifty OST patients were included, 54% of them accepted a new SC form of OST. Perceived causes of drug injection measured with EMIC were significantly lower among participants who would not accept the new SC form. No significant difference was found regarding the total score of the adapted ISMI or its items. The fear of opiate withdrawal syndrome did not seem to be statistically related to acceptance of a long-acting SC OST in either group. The most discriminating combination of factors in predicting patient acceptance of such treatment was related to the perceived causes of drug injection associated with a severe Diagnostic and Statistical Manual of Mental Disorders 5th version (DSM-5) diagnosis, and a lower alcohol consumption.

CONCLUSIONS

We observed significant differences in social representations but not in internalized stigma between the two groups. Moreover, the predictive factors linked to the acceptance of a new SC form of OST suggest a multifactorial combination of elements that will have to be tested in a larger and prospective study delivering long-acting high-dose buprenorphine.

Healthcare staff's perspectives on long-acting injectable buprenorphine treatment: a qualitative interview study

BACKGROUND

Long-acting injectable buprenorphine (LAIB) formulations are a novel treatment approach in opioid agonist treatment (OAT), which provide patients with a steady dose administered weekly or monthly and thus reduce the need for frequent clinic visits. Several studies have analyzed patient experiences of LAIB but the perspective of OAT staff is unknown. This study aimed to explore how healthcare staff working in OAT clinics in Sweden perceive and manage treatment with LAIB.

METHODS

Individual qualitative interviews were conducted with OAT physicians (n = 10) in tandem with nine focus group sessions with OAT nurses and other staff categories (n = 41). The data was analyzed with thematic text analysis.

RESULTS

Five central themes were identified in the data: (1) advantages and disadvantages of LAIB, (2) patient categories that may or may not need LAIB, (3) patients' degrees of medication choice, (4) keeping tabs, control and treatment alliance, and (5) LAIB's impact on risk and enabling environments in OAT. Overall staff found more advantages than disadvantages with LAIB and considered that patients with ongoing substance use and low adherence were most likely to benefit from LAIB. However, less frequent visits were viewed as problematic in terms of developing a treatment alliance and being able to keep tabs on patients' clinical status. Clinics differed regarding patients' degrees of choice in medication, which varied from limited to extensive. LAIB affected both risk and enabling environments in OAT.

CONCLUSIONS

LAIB may strengthen the enabling environment in OAT for some patients by reducing clinic visits, exposure to risk environments, and the pressure to divert medication. A continued discussion about the prerequisites and rationale for LAIB implementation is needed in policy and practice.

Health utility among people who regularly use opioids in Australia

INTRODUCTION

Studies of health utilities among people who use opioids have mostly been based on in-treatment populations. We aim to report utility-based quality of life by participants' socio-demographic, drug and treatment characteristics, and to examine the determinants of health utility among people who use opioids regularly.

METHODS

Cross-sectional study of participants who used opioids regularly, recruited across New South Wales, Victoria and Tasmania in 2018-2019. Differences in European Quality of Life (EQ-5D-5L) heath utility scores between socio-demographic and clinical subgroups were assessed using non-parametric Kruskal-Wallis test by rank. To address the unique distribution of EQ-5D-5L health utility scores in the current sample, a two-part model was applied to assess factors associated with health utility.

RESULTS

Among 402 participants enrolled in the study, 385 (96%) completed the EQ-5D-5L questionnaire. The mean health utility of the total sample was 0.63 (SD 0.29). Participants who previously received opioid agonist treatment [OAT] (adj marginal effect (ME) -0.11; 95% confidence interval [CI] -0.20 to -0.02) and those currently in OAT (adj ME -0.13; 95% CI -0.22 to -0.06) reported lower health utility than those who had never received OAT. Participants who used both pharmaceutical opioids and benzodiazepines had lower health utility compared to no pharmaceutical opioids and no benzodiazepines use (adj ME -0.17; 95% CI -0.28 to -0.07).

DISCUSSION AND CONCLUSIONS

Findings provide important health utility data for economic evaluations, useful for guiding allocation of resources for treatment strategies among people who use opioids. Lower health utilities among those using benzodiazepines and pharmaceutical opioids suggests interventions targeting these subgroups may be beneficial.

Incidence of hepatitis C virus infection in the prison setting: The SToP-C study

People in prison are at high risk of HCV given high injecting drug use prevalence. This study evaluated HCV incidence and associated injecting drug use characteristics in prison. The SToP-C study enrolled people incarcerated in four Australian prisons. Participants were tested for HCV at enrolment and then every 3-6 months (October-2014 to November-2019). Participants eligible for this analysis included those at-risk of HCV primary infection (anti-HCV negative) or re-infection (anti-HCV positive, HCV RNA negative) with follow-up assessment. A total of 1643 eligible participants were included in analyses (82% male; median age 33 years; 30% injected drugs in prison; 1818 person-years of follow-up). Overall HCV incidence was 6.11/100 person-years (95%CI: 5.07-7.35), with higher rate of re-infection (9.34/100 person-years; 95%CI: 7.15-12.19) than primary infection (4.60/100 person-years; 95%CI: 3.56-5.96). In total population (n = 1643), HCV risk was significantly higher among participants injecting drugs in prison [vs. no injecting; adjusted hazard ratio (aHR): 10.55, 95%CI: 5.88-18.92), and those who were released and re-incarcerated during follow-up (vs. remained incarcerated; aHR: 1.60, 95%CI: 1.03-2.49). Among participants who injected recently (during past month, n = 321), HCV risk was reduced among those receiving high-dosage opioid agonist therapy (OAT), i.e. methadone ≥60 mg/day or buprenorphine ≥16 mg/day, (vs. no OAT, aHR: 0.11, 95%CI: 0.02-0.80) and increased among those sharing needles/syringes without consistent use of disinfectant to clean injecting equipment (vs. no sharing, HR: 4.60, 95%CI: 1.35-15.66). This study demonstrated high HCV transmission risk in prison, particularly among people injecting drugs. High-dosage OAT was protective, but improved OAT coverage and needle/syringe programmes to reduce sharing injecting equipment are required.

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.

Buprenorphine versus methadone for the treatment of opioid dependence: a systematic review and meta-analysis of randomised and observational studies

BACKGROUND

Opioid dependence is associated with substantial health and social burdens, and opioid agonist treatment (OAT) is highly effective in improving multiple outcomes for people who receive this treatment. Methadone and buprenorphine are common medications provided as OAT. We aimed to examine buprenorphine compared with methadone in the treatment of opioid dependence across a wide range of primary and secondary outcomes.

METHODS

We did a systematic review and meta-analysis in accordance with GATHER and PRISMA guidelines. We searched Embase, MEDLINE, CENTRAL, and PsycINFO from database inception to Aug 1, 2022; clinical trial registries and previous relevant Cochrane reviews were also reviewed. We included all RCTs and observational studies of adults (aged ≥18 years) with opioid dependence comparing treatment with buprenorphine or methadone. Primary outcomes were retention in treatment at 1, 3, 6, 12, and 24 months, treatment adherence (measured through doses taken as prescribed, dosing visits attended, and biological measures), or extra-medical opioid use (measured by urinalysis and self-report). Secondary outcomes were use of benzodiazepines, cannabis, cocaine, amphetamines, and alcohol; withdrawal; craving; criminal activity and engagement with the criminal justice system; overdose; mental and physical health; sleep; pain; global functioning; suicidality and self-harm; and adverse events. Single-arm cohort studies and RCTs that collected data on buprenorphine retention alone were also reviewed. Data on study, participant, and treatment characteristics were extracted. Study authors were contacted to obtain additional data when required. Comparative estimates were pooled with use of random-effects meta-analyses. The proportion of individuals retained in treatment across multiple timepoints was pooled for each drug. This study is registered with PROSPERO (CRD42020205109).

FINDINGS

We identified 32 eligible RCTs (N=5808 participants) and 69 observational studies (N=323 340) comparing buprenorphine and methadone, in addition to 51 RCTs (N=11 644) and 124 observational studies (N=700 035) that reported on treatment retention with buprenorphine. Overall, 61 studies were done in western Europe, 162 in North America, 14 in north Africa and the Middle East, 20 in Australasia, five in southeast Asia, seven in south Asia, two in eastern Europe, three in central Europe, one in east Asia, and one in central Asia. 1 040 827 participants were included in these primary studies; however, gender was only reported for 572 111 participants, of whom 377 991 (66·1%) were male and 194 120 (33·9%) were female. Mean age was 37·1 years (SD 6·0). At timepoints beyond 1 month, retention was better for methadone than for buprenorphine: for example, at 6 months, the pooled effect favoured methadone in RCTs (risk ratio 0·76 [95% CI 0·67-0·85]; I·=74·2%; 16 studies, N=3151) and in observational studies (0·77 [0·68-0·86]; I·=98·5%; 21 studies, N=155 111). Retention was generally higher in RCTs than observational studies. There was no evidence suggesting that adherence to treatment differed with buprenorphine compared with methadone. There was some evidence that extra-medical opioid use was lower in those receiving buprenorphine in RCTs that measured this outcome by urinalysis and reported proportion of positive urine samples (over various time frames; standardised mean difference -0·20 [-0·29 to -0·11]; I·=0·0%; three studies, N=841), but no differences were found when using other measures. Some statistically significant differences were found between buprenorphine and methadone among secondary outcomes. There was evidence of reduced cocaine use, cravings, anxiety, and cardiac dysfunction, as well as increased treatment satisfaction among people receiving buprenorphine compared with methadone; and evidence of reduced hospitalisation and alcohol use in people receiving methadone. These differences in secondary outcomes were based on small numbers of studies (maximum five), and were often not consistent across study types or different measures of the same constructs (eg, cocaine use).

INTERPRETATION

Evidence from trials and observational studies suggest that treatment retention is better for methadone than for sublingual buprenorphine. Comparative evidence on other outcomes examined showed few statistically significant differences and was generally based on small numbers of studies. These findings highlight the imperative for interventions to improve retention, consideration of client-centred factors (such as client preference) when selecting between methadone and buprenorphine, and harmonisation of data collection and reporting to strengthen future syntheses.

FUNDING

Australian National Health and Medical Research Council.

Incidence of suicide and self-harm among people with opioid use disorder and the impact of opioid agonist treatment: A retrospective data linkage study

BACKGROUND

Rates of suicide and self-harm are elevated among people with opioid use disorder (OUD). This study examined incidence of self-harm and suicide among people who have entered OAT and assessed the impact of different OAT exposure periods on these events.

METHOD

We conducted a retrospective population-based cohort study of all OAT recipients (N = 45,664) in New South Wales, Australia (2002-2017), using linked administrative data. Incidence rates of self-harm hospitalisations and suicide deaths were estimated per 1000 person-years (PY). The first 28 days of an OAT episode, ≥ 29 days on OAT, the first 28 days off OAT, and ≥ 29 days off OAT (maximum four years post-OAT) were exposure periods. Poisson regression models with generalised estimating equations estimated the adjusted incidence rate ratios (ARR) of self-harm and suicide by OAT exposure periods, adjusting for covariates.

RESULTS

There were 7482 hospitalisations (4148 individuals) for self-harm and 556 suicides, equating to incidence rates of 19.2 (95% confidence intervals [CI]=18.8-19.7) and 1.0 (95%CI=0.9-1.1) per 1000 PY, respectively. Opioid overdose was implicated in 9.6% of suicides and 28% of self-harm hospitalisations. Compared to ≥ 29 days on OAT, the incidence rate of suicide was elevated in the 28 days following OAT cessation (ARR=17.4 [95%CI=11.7-25.9]), and the rate of self-harm hospitalisations was elevated during the first 28 days of OAT (ARR=2.2 [95%CI=1.9-2.6]) and the 28 days after leaving OAT (ARR=2.7 [95%CI=2.3-3.2]).

CONCLUSIONS

OAT may reduce suicide and self-harm risk among people with OUD; however, OAT initiation and cessation are critical periods for targeting self-harm and suicide prevention interventions.

'I just thought that was the best thing for me to do at this point': Exploring patient experiences with depot buprenorphine and their motivations to discontinue

INTRODUCTION

Long-acting injectable depot buprenorphine is a recent addition to the suite of opioid agonist therapies (OAT) used to treat opioid use disorder (OUD). However, there has been little research that focuses on the lived experience of people receiving depot buprenorphine treatment and reasons for why people decide to discontinue. The aim of this study was to explore what it is like to receive depot buprenorphine and to understand the motivations behind why people discontinue.

METHODS

Open-ended, semi-structured interviews were conducted between November 2021 and January 2022 with individuals who were either currently receiving depot buprenorphine or had discontinued or were in the process of discontinuing depot buprenorphine. Liberati, et al.'s (2022) adaptation of Dixon-Woods's (2006) candidacy framework was used to analyse the participant experiences.

RESULTS

40 participants (26 male, 13 female, 1 undisclosed; mean age 42 years) were interviewed about their experience with depot buprenorphine. At the time of the interview, 21 were currently receiving depot buprenorphine and 19 had discontinued this treatment or were in the process of discontinuing. Participants cited 4 key reasons why they decided to discontinue depot buprenorphine:1) feeling forced into the program, 2) experiencing negative side-effects, 3) finding the treatment ineffective, and 4) wanting to stop depot buprenorphine/OAT to use opioids again or feeling 'cured' and no longer in need of OAT. Participants were ultimately discussing issues related to clinician-patient power relations, agency and bodily autonomy, and the pursuit of well-being.

CONCLUSION

Depot buprenorphine remains a promising treatment for OUD and offers potential to improve treatment adherence. Instances of restricted OAT choice and consumer concerns regarding a lack of agency must be addressed in order to enhance therapeutic relationships. Clinicians and other healthcare workers in this field also need greater access to information about depot buprenorphine to better address issues patients face during treatment. More research is required to understand patient and treatment choice given the options of these new treatment formulations.

Taking a chance: How likely am I to receive my preferred treatment in a clinical trial?

Researchers should ideally conduct clinical trials under a presumption of clinical equipoise, but in fact trial patients will often prefer one or other of the treatments being compared. Receiving an unblinded preferred treatment may affect the study outcome, possibly beneficially, but receiving a non-preferred treatment may induce 'reluctant acquiescence', and poorer outcomes. Even in blinded trials, patients' primary motivation to enrol may be the chance of potentially receiving a desirable experimental treatment, which is otherwise unavailable. Study designs with a higher probability of receiving a preferred treatment (denoted as 'concordance') will be attractive to potential participants, and investigators, because they may improve recruitment and hence enhance study efficiency. Therefore, it is useful to consider the concordance rates associated with various study designs. We consider this question with a focus on comparing the standard, randomised, two-arm, parallel group design with the two-stage randomised patient preference design and Zelen designs; we also mention the fully randomised and partially randomised patient preference designs. For each of these designs, we evaluate the concordance rate as a function of the proportions randomised to the alternative treatments, the distribution of preferences over treatments, and (for the Zelen designs) the proportion of patients who consent to receive their assigned treatment. We also examine the equity of each design, which we define as the similarity between the concordance rates for participants with different treatment preferences. Finally, we contrast each of the alternative designs with the standard design in terms of gain in concordance and change in equity.

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.

Long-Acting Injectable Therapy for People with HIV: Looking Ahead with Lessons from Psychiatry and Addiction Medicine

Long-acting injectable antiretroviral medications are new to HIV treatment. People with HIV may benefit from a treatment option that better aligns with their preferences, but could also face new challenges and barriers. Authors from the fields of HIV, substance use treatment, and mental health collaborated on this commentary on the issues surrounding equitable implementation and uptake of LAI ART by drawing lessons from all three fields. We employ a socio-ecological framework beginning at the policy level and moving through the community, organizational, interpersonal, and patient levels. We look at extant literature on the topic as well as draw from the direct experience of our clinician-authors.

Buprenorphine and its formulations: a comprehensive review

Buprenorphine, a novel long-acting analgesic, was developed with the intention of two purposes: analgesia and opioid use disorder. Regarding its pharmacodynamics, it is a partial agonist at mu receptors, an inverse agonist at kappa receptors, and an antagonist at delta receptors. For the purpose of analgesia, three formulations of buprenorphine were developed: IV/IM injectable formulation (Buprenex®), transdermal patch formulation (Butrans®), and buccal film formulation (Belbuca®). Related to opioid dependence, the formulations developed were subcutaneous extended release (Sublocade®), subdermal implant (Probuphine®), and sublingual tablets (Subutex®). Lastly, in order to avoid misuse of buprenorphine for opioid dependence, two combination formulations paired with naloxone were developed: film formulation (Suboxone®) and tablet formulation (Zubsolv®). In this review, we present details of each formulation along with their similarities and differences between each other and clinical considerations.

Long-acting injectable buprenorphine - 'best practice' opioid agonist therapy for Australian prisoners

OBJECTIVE

To consider opioid agonist therapy in prisons.

CONCLUSIONS

Given the substantial risks of substance misuse by prisoners, long-acting injectable buprenorphine should be adopted as 'best practice' treatment in Australian prison populations.

Can a new formulation of opiate agonist treatment alter stigma?: Place, time and things in the experience of extended-release buprenorphine depot

INTRODUCTION

Stigma has corrosive effects on all aspects of care and can undermine individual and population health outcomes. Addiction-related stigma has implications for opiate agonist treatment (OAT) and the people who receive, provide and fund it. It is important to understand how stigma is made in OAT and the political purposes that it serves, in order to change the relations of stigma and avoid the reproduction of stigma in the delivery of new treatment formulations, such as extended release buprenorphine (BUP-XR).

METHODS

Semi-structured qualitative interviews were conducted at two time points with participants in a prospective single-arm, multicentre, open-label trial of monthly BUP-XR. Thirty-six participants (25 men, 11 women) were interviewed, and of these 32 participated in a second interview to explore their experience of transition from other treatment to BUP-XR.

RESULTS

Participants were highly aware of the of the social and material effects of stigma through the negative stereotypes attached to OAT and those who receive it. Participants narrated examples of how stigma governed as a biopower in the relations and practices of OAT provision at numerous levels: structural (such as in public discourse about OAT and the people who receive it, in media, in perceptions about the decisions of investment in medical technologies); organisational (policies about legitimate access to OAT); interpersonal (with health workers) and individual (self-identities). BUP-XR allowed greater freedom and normalcy for clients. The experience of BUP-XR drew attention to the stigmatising potential of time, place and things associated with other OAT requiring daily (or frequent) dosing, accentuating how stigma comes to be materialised as a relational effect of everyday practices.

CONCLUSIONS

Receiving BUP-XR allowed participants to avoid some of the everyday biopolitical powers of other forms of OAT and to reshape self-identities. The altering of relations between time, place and things associated with other forms of OAT allowed participants to feel as though they "pass as normal" . However, the negative public discourse and stigma of OAT is a potential threat to BUP-XR to realise its potential for individual and population benefits.

The impact of opioid agonist treatment on hospitalisations for injecting-related diseases among an opioid dependent population: A retrospective data linkage study

BACKGROUND

Injecting-related bacterial and fungal infections cause substantial illness and disability among people who use illicit drugs. Opioid agonist treatment (OAT) reduces injecting frequency and the transmission of blood borne viruses. We estimated the impact of OAT on hospitalisations for non-viral infections and examine trends in incidence over time.

METHODS

We conducted a retrospective cohort study using linked administrative data. The cohort included 47 163 individuals starting OAT between August 2001 and December 2017 in New South Wales, Australia, with 454 951 person-years of follow-up. The primary outcome was hospitalisation for an injecting-related disease. The primary exposure was OAT status (out of OAT, first four weeks of OAT, and OAT retention [i.e., more than four weeks in treatment]). Covariates included demographic characteristics, year of hospitalisation, and recent clinical treatment.

RESULTS

9122 participants (19.3%) had at least one hospitalisation for any injecting-related disease. Compared to time out of treatment, retention on OAT was associated with a reduced rate of injecting-related diseases (adjusted rate ratio[ARR]=0.92; 95%CI 0.87-0.97). The first four weeks of treatment was associated with an increased rate (ARR 1.53, 95%CI 1.38-1.70), which we believe is explained by referral pathways between hospital and community OAT services. The age-adjusted incidence rates of hospitalisations for any injecting-related disease increased from 34.8 (95% CI =30.2-40.0) per 1000 person-years in 2001 to 54.9 (95%CI=51.3-58.8) in 2017.

INTERPRETATION

Stable OAT is associated with reduced hospitalisations for injecting-related bacterial infections; however, OAT appears insufficient to prevent these harms as the rate of these infections is increasing in Australia.

Patient perspectives on depot buprenorphine treatment for opioid addiction - a qualitative interview study

BACKGROUND

Recently developed buprenorphine depot injections have the potential to reduce risk for diversion and misuse, and to increase adherence with fewer visits for supervised intake. However, it is unclear how patients perceive this new form of medication. The purpose of this study was to explore patients' experiences of depot injections and their reasons for continuing, discontinuing, or declining depot injection treatment.

METHODS

We conducted semi-structured qualitative interviews with 32 people, 14 of whom had ongoing depot injection treatment, 11 who had discontinued depot-injections and switched to other medication and seven who had declined treatment with depot formulations. Interviews were transcribed, coded, and analysed using NVivo, based on this overall stratification into three participant groups.

RESULTS

The main categories relate to the effects and side effects of the depot formulation, social and practical factors, psychological benefits and disadvantages, and interactions with treatment staff. Social and practical factors were of importance for choosing depot formulations, such as increased freedom and their making it easier to combine treatment with work and family life, as well as psychological advantages including "feeling normal". Initial withdrawal symptoms that resolved themselves after a number of injections were reported by most participants. Reliable information and patient-staff relationships characterized by trust helped patients to cope with these initial problems. Those who discontinued treatment often did so near the beginning of the treatment, reporting withdrawal symptoms and insufficient effects as the main reasons. Coercion and insufficient information contributed to a negative pharmaceutical atmosphere at one of the clinics, which may have adversely influenced perceptions of depot formulations and decreased willingness to accept and continue treatment.

CONCLUSIONS

Buprenorphine depot injections may have social, practical, and psychological benefits compared to other formulations. However, depot injections are not perceived as an attractive option by all patients. Trust, consistent and adequate information, and awareness of the implications of the pharmaceutical atmosphere should be considered when introducing new medications.

Examining the cost and impact of dosing fees among clients in opioid agonist treatment: Results from a cross-sectional survey of Australian treatment clients

INTRODUCTION

Opioid agonist treatment (OAT) clients frequently bear costs associated with their treatment, including dosing fees. This study aimed to explore the financial and social impact of dosing fees upon clients.

METHODS

Cross-sectional survey of people who use opioids regularly (N = 402) between December 2017 and March 2018, conducted in Australia. Dosing fees were calculated and expressed as percentage of income, by OAT type. Consequences and strategies for difficulties making payments were examined as proportions.

RESULTS

A total of N = 360 participants had ever been in OAT and N = 245 participants currently engaged in OAT reported data on dosing fees, of them 53% (n = 129) reported paying dosing fees. Compared to clients with high levels of dosing supervision, those with moderate or low levels of supervision were more likely to pay dosing fees. The median 28-day dosing fee was AUD$110 (interquartile range AUD$80); median 28-day income was AUD$1520 (interquartile range AUD$700). For those who paid dosing fees, the fee comprised <10% of total monthly income for 70% of participants; however, 23% of participants paid fees comprising 10% to <20%, and 7% of participants paid fees comprising 20% or more of monthly income. Among those that had ever been in OAT, 72% experienced difficulties in paying treatment costs; 36% left treatment earlier than intended and 25% had been excluded due to payment difficulties.

DISCUSSION AND CONCLUSIONS

Negative consequences of treatment costs to clients, particularly dosing fees, are evident. These costs impact treatment access and retention that may negatively impact clients' physical health, mental health and social wellbeing.

Endogenous opiates and behavior: 2020

This paper is the forty-third consecutive installment of the annual anthological review of research concerning the endogenous opioid system, summarizing articles published during 2020 that studied the behavioral effects of molecular, pharmacological and genetic manipulation of opioid peptides and receptors as well as effects of opioid/opiate agonists and antagonists. The review is subdivided into the following specific topics: molecular-biochemical effects and neurochemical localization studies of endogenous opioids and their receptors (1), the roles of these opioid peptides and receptors in pain and analgesia in animals (2) and humans (3), opioid-sensitive and opioid-insensitive effects of nonopioid analgesics (4), opioid peptide and receptor involvement in tolerance and dependence (5), stress and social status (6), learning and memory (7), eating and drinking (8), drug abuse and alcohol (9), sexual activity and hormones, pregnancy, development and endocrinology (10), mental illness and mood (11), seizures and neurologic disorders (12), electrical-related activity and neurophysiology (13), general activity and locomotion (14), gastrointestinal, renal and hepatic functions (15), cardiovascular responses (16), respiration and thermoregulation (17), and immunological responses (18).

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.

Outcomes of a single-arm implementation trial of extended-release subcutaneous buprenorphine depot injections in people with opioid dependence

BACKGROUND

Opioid agonist treatment (OAT) is an effective intervention for opioid dependence. Extended-release buprenorphine injections (BUP-XR) may have additional potential benefits over sublingual buprenorphine. This single-arm trial evaluated outcomes among people receiving 48 weeks of BUP-XR in diverse community healthcare settings in Australia, permitting examination of outcomes when BUP-XR is delivered in standard practice.

METHODS

Participants were recruited from a network of specialist public drug treatment services, primary care and some private practices in three states. Following a minimum 7 days on 8-32 mg of sublingual buprenorphine (±naloxone), participants received monthly subcutaneous BUP-XR injections administered by a healthcare practitioner and completed monthly research interviews. The primary endpoint was retention in treatment at 48 weeks.

FINDINGS

Participants (n = 100) were 28% women, mean age 44 years with a long history of OAT (median 5.8 years); heroin was the most common opioid of concern (58%). Treatment retention at 24 and 48 weeks was 86% and 75%, respectively. Participants with past-month injecting drug use (OR 0.23; 95%CI: 0.09-0.61) or heroin use (OR 0.23; 95%CI: 0.08-0.65) at baseline had lower odds of being retained in treatment to 48 weeks. Reductions in multiple forms of extra-medical drug use were observed. Improvements in quality of life, participation in employment, and treatment satisfaction measures were also observed.

INTERPRETATION

This real-world implementation study of BUP-XR demonstrated high retention and treatment satisfaction. This study provides important additional data on the uptake and experience of clients, with relevance for policy makers, health service planners, administrators, and practitioners.

FUNDING

Indivior.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT03809143.

Economic analysis of out-of-pocket costs among people in opioid agonist treatment: A cross-sectional survey in three Australian jurisdictions

BACKGROUND

Out-of-pocket costs for opioid agonist treatment (OAT) constitute a barrier to treatment entry and retention.This study examines OAT clients' total out-of-pocket costs (including dispensing fees, travel costs and OAT-related appointment costs) in different treatment settings (public clinics, community pharmacies, and private clinics).

METHODS

Cross-sectional survey of 402 people with opioid drug use (OUD) in New South Wales (NSW), Victoria (VIC), Tasmania (TAS), Australia; 266 clients (66%) currently receiving methadone, buprenorphine or buprenorphine-naloxone treatment were asked about dispensing fees, travel costs and OAT-related appointment costs in the past 28 days. A two-part regression model was used to deal with non-normal distributions of costing data (right skew and excess zeros).

RESULTS

Among clients currently receiving OAT, 87% paid out-of-pocket costs. Among those who paid out-of-pocket costs (N=194), travel costs accounted for more than half of total costs (52%), followed by dispensing fees (44%). The mean monthly total out-of-pocket costs were AU$135 (SD: AU$121) for public clinics, AU$161 (SD: AU$110) to AU$214 (SD: AU$166) for community pharmacies and AU$355 (SD: AU$159) for private clinics. Compared to participants in NSW private clinics, those at public clinics paid one third the total out-of-pocket costs (coefficient = 0.33; 95%CI = 0.23-0.48) and those at NSW, TAS, VIC pharmacies paid approximately half the costs (coefficient = 0.58; 95%CI = 0.42-0.79; coefficient = 0.51; 95%CI = 0.36-0.72; coefficient = 0.47; 95%CI = 0.34-0.66, respectively). People in OAT for more than a year paid half the total out-of-pocket costs, compared with those in OAT less than a year (coefficient = 0.49, 95%CI = 0.31-0.77).

CONCLUSIONS

Participants in the current study spent one-eighth of their income on out-of-pocket costs associated with OAT representing a substantial financial burden. Total out-of-pocket costs disproportionately affects those who are newer in treatment and receiving fewer unsupervised doses. Considering and addressing total out-of-pocket costs, especially travel costs and dispensing fees, to clients is critical to prevent cost from being a barrier from receiving effective care.

Tracing the affordances of long-acting injectable depot buprenorphine: A qualitative study of patients' experiences in Australia

BACKGROUND

Long-acting injectable depot buprenorphine is an important new treatment option for the management of opioid dependence, delivering therapeutic doses in weekly or monthly formulations. Depot buprenorphine aims to overcome challenges associated with traditional opioid agonist therapy (OAT), including: poor patient adherence; inconvenience of regular attendance for dosing; and, risk of non-medical use of takeaway doses. However, little is known about patients' experiences of depot buprenorphine. This qualitative study aimed to explore patients' experiences of the practical and social affordances of depot buprenorphine.

METHODS

Participants were recruited from sites in Sydney, regional New South Wales, and Melbourne, Victoria, Australia. Thirty participants (16 men, 14 women; mean age 47.3 years) participated in semi-structured interviews. Participants had histories of both heroin and prescription opioid use, and previous OAT including daily dosing of buprenorphine and methadone.

FINDINGS

Depot buprenorphine afforded positive benefits for many participants, including: opportunities to avoid stigma experienced at pharmacies/clinics; time to engage in activities (e.g., travel, work) by releasing participants from previous OAT treatment regimens; and, cost savings by not having to pay pharmacy fees associated with daily dosing. However, for some participants, moving to depot buprenorphine: disrupted engagements with important social/practical supports available at pharmacies/clinics; constrained their control over dosing; and, constrained their ability to generate income via the sale of takeaway doses.

CONCLUSIONS

While generally experienced as affording benefits, depot buprenorphine can have differing social and practical impacts. Clinicians should monitor patients receiving depot buprenorphine to reduce the risk of unintended consequences including disruption to clinical supports.

Recent advances in the treatment of opioid use disorders-focus on long-acting buprenorphine formulations

Oral methadone or sublingual buprenorphine are first-line medications for pharmacotherapy of opioid use disorders (OUDs). Three long-acting buprenorphine depot or implant formulations are currently available for the treatment of OUDs: (1) CAM 2038 (Buvidal) for subcutaneous weekly and monthly application; (2) RBP-6000 (Sublocade™) as a monthly depot formulation; and (3) A six-month buprenorphine implant [Probuphine™]. The pharmacology, clinical efficacy and prospects of these medications are discussed.

Reprint of: Biotechnologies and the future of opioid addiction treatments

The future of treatment-including addiction treatment-is biotechnological. Depot injections, agonist/antagonist implants, deep brain stimulation, and hapten conjugate vaccines are hailed by researchers and pharmaceutical manufacturers as medicine's best hope to minimize illicit use, to decrease risk of overdose and painful withdrawal, and to prevent diversion of medicines to illicit markets. Marketing and use of new technologies reveal old tensions framing concepts of addiction and its treatment: between medical condition and disorder of the will, between criminal justice and health, and between patient choice and system control. Using the examples of depot naltrexone and implantable and injectable buprenorphine in the U.S., this essay considers the arc of long-acting opioid treatment and implications for the future. These include the rise of Vivitrol courts and "carceral prescription"-where criminal justice systems mandate medicine to lock up brain receptors much as they might lock up people themselves-as well as use of buprenorphine formulations positioned as increasing both patient benefit and provider control. We also consider lessons from debates on long-acting contraceptive technologies such as Norplant and Depo-Provera. While multiple new long-acting formulations are under development, success will be determined less by characteristics of particular formulations and more by whether or not the new technologies are accompanied by a new ethics of addiction treatment that emphasizes therapeutic alliance, concordance over compliance, and a genuine commitment to allowing patients the ability to narrate and be believed in their descriptions of their treatment experiences.

Perceptions of injectable opioid agonist treatment (iOAT) among people who regularly use opioids in Australia: findings from a cross-sectional study in three Australian cities

BACKGROUND AND AIMS

Not all people experiencing opioid dependence benefit from oral opioid agonist treatment. The aim of this study was to examine perceptions of (supervised) injectable opioid agonist treatment (iOAT) (described as 'an opioid similar to heroin self-injected at a clinic several times a day') among people who regularly use opioids and determine how common iOAT eligibility criteria accord with interest in iOAT.

DESIGN

Cross-sectional survey SETTING: Sydney, Melbourne and Hobart, Australia PARTICIPANTS: A total of 344 people (63% male) who use opioids regularly and had ever injected opioids, interviewed December 2017-March 2018. The mean age of participants was 41.5 years [standard deviation (SD) = 8.5].

MEASUREMENTS

Primary outcome measures were interest in iOAT, factors associated with interest and the proportion of participants who would be eligible using common criteria from trials and guidelines. We examined willingness to travel for iOAT, medication preferences and perspectives on whom should receive iOAT.

FINDINGS

Overall, 53% of participants (n = 182) believed that iOAT would be a good treatment option for them. Participants who believed that iOAT was a good treatment option for them were more likely to be male [adjusted odds ratio (aOR) = 1.76, 95% confidence interval (CI) = 1.10-2.82], have used heroin in the past month (aOR = 6.03, 95% CI = 2.86-12.71), currently regularly inject opioids (aOR = 1.84, 95% CI = 1.16-2.91) and have met ICD-10 criteria for opioid dependence (aOR = 3.46, 95% CI = 1.65-7.24). Those interested in iOAT had commenced more treatment episodes (aOR =1.06, 95% CI = 1.00-1.12). Among those interested in iOAT (n = 182), 26% (n = 48) met common eligibility criteria for iOAT.

CONCLUSIONS

Interest in injectable opioid agonist treatment does not appear to be universal among people who regularly use opioids. Among study participants who expressed interest in injectable opioid agonist treatment, most did not meet common eligibility criteria.

Retention of opioid agonist treatment prescribers across New South Wales, Australia, 2001-2018: Implications for treatment systems and potential impact on client outcomes

BACKGROUND

There has been much research on the efficacy and effectiveness of opioid agonist treatment (OAT), but less on its implementation and sustainability. A challenge internationally has been recruiting and retaining prescribers. This paper aims to characterise the prescribers in terms of OAT prescribing behaviours.

METHODS

Retrospective cohort study in New South Wales, Australia. Participants were 2199 OAT prescribers between 1 st August 2001-19th September 2018.We examined trends in initiation and cessation of OAT prescribers. Adjusted hazard ratios were calculated to estimate prescriber retention, adjusting for year of initiation, practice type, client load and treatment prescribed.

RESULTS

The rate of prescribers ceasing OAT prescribing has been increasing over time: a prescriber who initiated between 2016-2017 had over four times the risk of cessation compared with one who initiated before 2001, AHR: 4.77; [3.67-6.21]. The highest prescriber cessation rate was in prescribers who had prescribed for shorter time periods. The annual percentage of prescribers who ceased prescribing among those who prescribed for ≤5 years increased from 3% in 2001 to 20 % in 2017. By 2017 more prescribers were discontinuing prescribing than new prescribers were starting. Approximately 87 % (n = 25,167) of OAT clients were under the care of 20 % of OAT prescribers (n = 202); half had been prescribing OAT for 17+ years.

CONCLUSIONS

OAT prescribing is increasingly concentrated in a small group of mature prescribers, and new prescribers are not being retained. There is a need to identify and respond to the reasons that contribute to newer prescribers to cease prescribing and put in place strategies to increase retention and broaden the base of doctors involved in such prescribing.

Factors of Interest in Extended-Release Buprenorphine: Comparisons Between Incarcerated and Non-Incarcerated Patients with Opioid Use Disorder

PURPOSE

Extended-release buprenorphine (XR-BUP) covers a range of formulations of buprenorphine-based treatments for opioid use disorder (OUD) that release the medication over a period of one week, one month, or six months. OUD is particularly prevalent among incarcerated populations, and previous findings have shown that incarcerated subjects were not less interested in XR-BUP than non-incarcerated subjects. However, no study has ever investigated whether the factors of interest in XR-BUP were similar in incarcerated and non-incarcerated populations.

PATIENTS AND METHODS

We carried out post-hoc analyses using data from the "AMBRE" survey, which was conducted among 366 individuals with OUD, that were recruited in 68 French addiction settings, including six prison medical centers. The reasons for interest in XR-BUP were compared between incarcerated and non-incarcerated interviewees, using logistic regressions models, which provided raw and adjusted odds ratios (aORs) and 95% confidence intervals (95% CI). Adjustment variables were gender, age category, level of education, and type of current medication for OUD, respectively.

RESULTS

Data from 317 participants (ie, 221 non-incarcerated, and 96 incarcerated individuals) were included in the analyses. Adjusted comparisons found that "no longer taking a daily treatment" (aOR= 2.91; 95% CI= 1.21-6.98) and "having a more discreet medication" (aOR= 1.76; 95% CI= 1.01-3.10) were reasons that appealed more to incarcerated participants than to non-incarcerated ones. On the other hand, the potential reduction of withdrawal symptoms (aOR= 0.54; 95% CI= 0.29-0.99) or the risk of misuse (aOR= 0.56; 95% CI= 0.34-0.94) associated with XR-BUP treatment were considered more important by non-incarcerated individuals than by incarcerated ones.

CONCLUSION

Incarcerated interviewees were interested in XR-BUP for different reasons than those outside prison. In particular, incarcerated patients were more interested in practicability and discretion features, and less in improving recovery or reducing misuse than non-incarcerated patients.

Hospitalisations for non-fatal overdose among people with a history of opioid dependence in New South Wales, Australia, 2001-2018: Findings from the OATS retrospective cohort study

BACKGROUND

To examine, among a cohort of opioid dependent people with a history of opioid agonist treatment (OAT), the frequency and incidence rates of non-fatal overdose (NFOD) hospital separations over time, by age and sex.

METHODS

Retrospective cohort study of people with a history of OAT using state-wide linked New South Wales (NSW) data. The incidence of NFOD hospital separations involving an opioid, sedative, stimulant or alcohol was defined according to the singular or combination of poisoning/toxic effect using ICD-10-AM codes. Crude incidence rates were calculated by gender, age group and calendar year.

RESULTS

There were 31.8 (31.3-32.3) NFOD per 1,000 person-years (PY). Opioid NFOD incidence was higher in women than men: incidence rate ratio (IRR) 1.11 per 1,000PY; 95 %CI: [1.06-1.17]; women had higher sedative NFOD rates than men, IRR 1.27 per 1,000PY [1.21-1.34]. Participants ≤25 years, 26-30yrs, and 31-35yrs had higher incidence of opioid NFOD compared to 46+yrs, with IRRs of: 1.45 per 1,000PY; [1.32-1.59]; 1.20 per 1,000PY; [1.11-1.30] and 1.22 per 1,000PY; [1.13-1.32], respectively. Between 2006-7 and 2016-17, the cohort accounted for 19 % of NSW opioid NFOD episodes, 12 % of sedative, 14 % of stimulant and 5 % of acute alcohol-related NFOD.

CONCLUSIONS

Hospital stays due to NFOD are a relatively frequent occurrence among opioid-dependent people. There are clear differences in rates and substances involved by sex, age and over time. Evidence-based interventions that prevent overdose among people who are opioid dependent need to be delivered to scale, including widespread community provision of naloxone.

Risk of discharge against medical advice among hospital inpatients with a history of opioid agonist therapy in New South Wales, Australia: A cohort study and nested crossover-cohort analysis

BACKGROUND

People who use illicit opioids have high rates of hospital admission. We aimed to measure the risk of discharge against medical advice among inpatients with a history of opioid agonist therapy (OAT), and test whether OAT is associated with lower risk of discharge against medical advice.

METHODS

We conducted a cohort study of patients admitted to hospital in an emergency between 1 August 2001 and 30 April 2018 in New South Wales, Australia. All patients had a previous episode of OAT in the community. The main outcome was discharge against medical advice, and the main exposure was whether patients had an active OAT permit at the time of admission.

RESULTS

14,035/116,957 admissions (12 %) ended in discharge against medical advice. Admissions during periods of OAT had 0.79 (0.76-0.83; p < 0.001) times the risk of discharge against medical advice, corresponding to an absolute risk reduction of 3.0 percentage points. Risk of discharge against medical advice was higher among patients who were younger, male, identified as Aboriginal and/or Torres Strait Islander, and those admitted for accidents, drug-related reasons, or injecting-related injuries (such as cutaneous abscesses). In a subsample of 7793 patients included in a crossover-cohort analysis, OAT was associated with 0.84 (95 % CI 0.76-0.93; p < 0.001) times the risk of discharge against medical advice.

CONCLUSIONS

Among patients with a history of OAT, one in eight emergency hospital admissions ends in discharge against medical advice. OAT enrolment at the time of admission is associated with a reduction of this risk.

Biotechnologies and the future of opioid addiction treatments

The future of treatment-including addiction treatment-is biotechnological. Depot injections, agonist/antagonist implants, deep brain stimulation, and hapten conjugate vaccines are hailed by researchers and pharmaceutical manufacturers as medicine's best hope to minimize illicit use, to decrease risk of overdose and painful withdrawal, and to prevent diversion of medicines to illicit markets. Marketing and use of new technologies reveal old tensions framing concepts of addiction and its treatment: between medical condition and disorder of the will, between criminal justice and health, and between patient choice and system control. Using the examples of depot naltrexone and implantable and injectable buprenorphine in the U.S., this essay considers the arc of long-acting opioid treatment and implications for the future. These include the rise of Vivitrol courts and "carceral prescription"-where criminal justice systems mandate medicine to lock up brain receptors much as they might lock up people themselves-as well as use of buprenorphine formulations positioned as increasing both patient benefit and provider control. We also consider lessons from debates on long-acting contraceptive technologies such as Norplant and Depo-Provera. While multiple new long-acting formulations are under development, success will be determined less by characteristics of particular formulations and more by whether or not the new technologies are accompanied by a new ethics of addiction treatment that emphasizes therapeutic alliance, concordance over compliance, and a genuine commitment to allowing patients the ability to narrate and be believed in their descriptions of their treatment experiences.

COVID-19 and the health of people who use drugs: What is and what could be?

SARS-CoV-2, the virus that causes COVID-19, has changed the world as we know it, and continues to do so. How COVID-19 affects people who use drugs, the environments in which they live, and capacities of response, warrants immediate attention. This special issue begins to map how COVID-19 is altering the health of people who use drugs, including in relation to patterns of drug use, service responses, harms that may relate to drug use, interventions to reduce risk of harms, COVID-19 health, and drug policies. We emphasise the need to envisage COVID-19 and its effects as a matter of intersecting ‘complex adaptive systems’: that is, the impacts of COVID-19 extend beyond the virus and related illness conditions to encompass multiple social, cultural, economic, policy and political effects; and these affect the health of people who use drugs directly as well as indirectly by altering the risk and enabling environments in which they live. We synthesize emergent evidence on the impact of COVID-19 on the health of people who use drugs. A key concern we identify is how to sustain policy and service delivery improvements prompted by COVID-19. We need to maintain an ethos of emergent adaptation and experimentation towards the creation of safer environments in relation to the health of people who use drugs.

Novel Long-Acting Buprenorphine Medications for Opioid Dependence: Current Update

Opioid maintenance treatment with oral methadone or sublingual buprenorphine is the first-line treatment in opioid dependence. Three novel long-acting buprenorphine formulations have been approved or will be available soon: for subcutaneous weekly and monthly application, the depot formulations CAM 2038 (Buvidal^®), the monthly depot formulation RBP-6000 (Sublocade™), and a 6-month buprenorphine implant (Probuphine™). Clinical data available so far on the efficacy of these 3 medications are given, and possible clinical implications are discussed.

Patient-Reported Outcomes, Experiences and Satisfaction with Weekly and Monthly Injectable Prolonged-Release Buprenorphine

Introduction

Prolonged-release buprenorphine (PRB), administered by weekly or monthly injection, for opioid dependence (OD) treatment offers the potential to address some limitations of oral therapy including stigma, difficulty in achieving consistent appropriate dosing, risk of diversion of medications, risk of overdose, and continuing use of other drugs. Patient-reported outcomes (PRO) and experiences are important in the evaluation of OD therapy success. This work aimed to document PRO during PRB therapy to guide future treatment decision-making.

Methods

Qualitative interviews were completed with people on PRB OD treatment. Twenty individuals from four treatment services in England and Wales were asked to participate. A structured interview was developed guided by a person with OD lived experience. Interviews were transcribed, coded and analyzed using iterative categorization.

Results

Fifteen of 20 individuals approached agreed to participate, and 14 completed interviews. The average age of participants was 42 (range 33–54) years, 13 males and 1 woman, the history of problematic opioid use was 14 years (3–25 years), time in treatment was 7 years (1–20 years), and duration on treatment with PRB was 4 months (range 1–8 months). Participants reported treatment experiences leading to coding of 277 unique comments: therapy effectiveness (77% indicated a benefit of, or satisfaction with, PRB therapy, 7% neutral/general, 16% indicated concern or questions about PRB therapy), convenience (81% benefit, 7% neutral/general, 12% concern), and overall satisfaction (81% benefit, 3% neutral/general, 16% concern). Reported benefits include cravings reduction of 10 (71%), self-care improvement of 10 (71%), relationships improvement of 9 (64%), resources management of 6 (43%), positive outlook on life of 12 (86%). Participants reported a range of positive personal experiences; challenges reported included temporary injection discomfort at treatment initiation.

Discussion

In this small, focused population, there was generally a positive level of treatment satisfaction with PRB. These experiences provide insights to explain potential treatment benefit to others and are useful in guiding therapy choices for others in the future.

Open-label, multicentre, single-arm trial of monthly injections of depot buprenorphine in people with opioid dependence: protocol for the CoLAB study

INTRODUCTION

Opioid agonist treatment is effective for opioid dependence and newer extended-release buprenorphine (BUP-XR) injections represent a significant development. The Community Long-Acting Buprenorphine (CoLAB) study aims to evaluate client outcomes among people with opioid dependence receiving 48 weeks of BUP-XR treatment, and examines the implementation of BUP-XR in diverse community healthcare settings in Australia.

METHODS AND ANALYSIS

The CoLAB study is a prospective single-arm, multicentre, open-label trial of monthly BUP-XR injections in people with opioid dependence. Participants are being recruited from a network of general practitioner and specialist drug treatment services located in the states of New South Wales, Victoria and South Australia in Australia. Following a minimum 7 days on 8-32 mg of sublingual buprenorphine (±naloxone), participants will receive monthly subcutaneous BUP-XR injections administered by a healthcare practitioner at intervals of 28 days (-2/+14 days). The primary endpoint is participant retention in treatment at 48 weeks after treatment initiation. Secondary endpoints will evaluate dosing schedule variations, craving, withdrawal, substance use, health and well-being, and client-reported treatment experience. Qualitative and costing substudies will examine implementation barriers and facilitators at the client and provider level.

ETHICS AND DISSEMINATION

The study has received ethics approval from the St Vincent's Hospital Sydney Human Research Ethics Committee (Ref. HREC/18/SVH/221). The findings will be disseminated via publication in peer-reviewed journals, presentations at national and international scientific conferences, and in relevant community organisation publications and forums.

TRIAL REGISTRATION NUMBER

NCT03809143 PROTOCOL IDENTIFIER: CoLAB1801, V.4.0 dated 01 August 2019.

Perceptions of extended-release buprenorphine injections for opioid use disorder among people who regularly use opioids in Australia

AIMS

To examine perceptions of extended-release (XR) buprenorphine injections among people who regularly use opioids in Australia.

DESIGN

Cross-sectional survey prior to implementation. XR-buprenorphine was registered in Australia in November 2018.

SETTING

Sydney, Melbourne and Hobart. Participants A total of 402 people who regularly use opioids interviewed December 2017 to March 2018.

MEASUREMENTS

Primary outcome concerned the proportion of participants who believed XR-buprenorphine would be a good treatment option for them, preferred weekly versus monthly injections and perceived advantages/disadvantages of XR-buprenorphine. Independent variables concerned the demographic characteristics and features of current opioid agonist treatment (OAT; medication-type, dose, prescriber/dosing setting, unsupervised doses, out-of-pocket expenses and travel distance).

FINDINGS

Sixty-eight per cent [95% confidence interval (CI) = 63-73%] believed XR-buprenorphine was a good treatment option for them. They were more likely to report being younger [26-35 versus > 55 years; odds ratio (OR) = 3.16, 95% CI = 1.12-8.89; P = 0.029], being female (OR = 1.67, 95% CI = 1.04-2.69; P = 0.034), < 10 years school education (OR = 1.87, 95% CI = 1.12-3.12; P = 0.016) and past-month heroin (OR = 1.81, 95% CI = 1.15-2.85; P = 0.006) and methamphetamine use (OR = 1.90, 95% CI = 1.20-3.01; P = 0.006). Fifty-four per cent reported no preference for weekly versus monthly injections, 7% preferred weekly and 39% preferred monthly. Among OAT recipients (n = 255), believing XR-buprenorphine was a good treatment option was associated with shorter treatment episodes (1-2 versus ≥ 2 years; OR = 3.93, 95% CI = 1.26-12.22; P = 0.018), fewer unsupervised doses (≤ 8 doses past-month versus no take-aways; OR = 0.50; 95% CI = 0.27-0.93; P = 0.028) and longer travel distance (≥ 5 versus < 5 km; OR = 2.10, 95% CI = 1.20-3.65; P = 0.009). Sixty-nine per cent reported 'no problems or concerns' with potential differences in availability, flexibility and location of XR-buprenorphine.

CONCLUSIONS

Among regular opioid users in Australia, perceptions of extended-release buprenorphine as a good treatment option are associated with being female, recent illicit drug use and factors relating to the (in)convenience of current opioid agonist treatment.

Commentary on Larance et al. (2020): Priorities and concerns of people who use opioids are key to scaling up XR-buprenorphine

Larence et al.’s findings have key implications for XR-buprenorphine guidelines as it becomes available internationally. These are to embrace less-onerous dosing schedules, to consider incorporating into standard-of-care an option to supplement with transmucosal buprenorphine between injections, and to investigate what possibilities XR-buprenorphine opens up for patients wanting to taper off opioid agonist treatment.