Thursday, March 1, 2018

Treatment for Opioid Use Disorder Continues to Evolve - a brief summary

Currently there are basically 6 recognized treatment approaches that include counseling and psychosocial support in various treatment settings to treat moderate to severe opioid use disorder (heroin and/or pain medication addiction). All have certain advantages and disadvantages which can be summarized as follows:

1.    Cold turkey, or non-medical detox, followed by complete abstinence
     Advantages: low cost
    Disadvantages: high failure rate
2.    Medically prescribed detox or withdrawal management, with or without buprenorphine or methadone used in a taper, followed by abstinence
    Advantages: less discomfort during withdrawal
    Disadvantages: high failure rate after treatment episode is complete
3.    Detox (medical or non-medical) followed by initiation of a naltrexone containing product such as Vivitrol, Revia or a non-FDA approved naltrexone implant
    Advantages: Effective as long as the individual remains motivated or able to stay on the naltrexone as prescribed
    Disadvantages: Abstinence from all opioids is usually required for several days prior to initiation of treatment.
4.    Methadone maintenance
    Advantages: effective for select individuals using established, well studied treatment protocols
    Disadvantages: Restrictive and often impractical due to current Federal laws
5.    Oral administration of a buprenorphine containing product such as Suboxone, Subutex, Zubsolv, Bunavail or their generic equivalents.
     Advantages: Effective, well tolerated, accessible through a licensed prescriber
    Disadvantages: problematic in certain settings such as incarceration, unstable housing, and sober living homes due to misuse and diversion. Difficult to monitor treatment compliance at times.
6.    Probuphine which is a 6 month, long-acting buprenorphine implant in the arm

    Advantages: effective in a select population. Addresses many concerns over medication compliance, diversion or misuse during the 6-month implant period.
    Disadvantages: must be administered in a structured medical setting by a physician that has been trained and certified for insertion and removal of the implants using minor surgical technique. Possible complications related to performing this type of invasive surgical procedure.

There is now a 7th approach that will be available starting March 2018 that is expected to be effective, accessible and able to address the frequent problems of compliance, diversion, and misuse of buprenorphine containing products. This new product is being introduced by the same company that released Suboxone in 2003 and revolutionized how we look at and treat opioid use disorders. This new product received FDA approval in November 2017 based on favorable data as a completely new buprenorphine delivery system and will be marketed as Sublocade.
Sublocade is a Schedule III (CIII) once monthly buprenorphine extended-release subcutaneous injection that can easily be administered by a physician or other qualified healthcare provider that is currently licensed to prescribe buprenorphine containing products.
Because Sublocade is injected once a month in a controlled setting under medical supervision, the chance of misuse or diversion is likely to be very low. It is expected that most insurances will cover this treatment as part of a structured treatment program that includes counseling and psychosocial support.