Extended-Release Buprenorphine for Patients with Opioid Use Disorder at Hospital Discharge

Case Presentation:

AS is 36-year-old woman with methamphetamine and opioid use disorder (OUD) hospitalized with endocarditis who is evaluated by the Addiction Consult Service (ACS), and started on sublingual Buprenorphine/naloxone (Bup/nx) for treatment of OUD. Urine drug screens continue to be inappropriately positive for methamphetamine inpatient. Extended-Release Buprenorphine (Bup-XR) is discussed and with her agreement administered prior to discharge to increase buprenorphine adherence, reduce risk of overdose from contaminated stimulants, and avoid bup/nx diversion. She continues outpatient treatment with Bup-XR for OUD and counseling for stimulant use disorder.

LS is a 47-year-old man with OUD hospitalized with endocarditis and started on sublingual Bup/nx. Patient is administered Bup-XR prior to discharge as he did not have access to transportation for frequent follow ups.

CW is a 30-year-old female with OUD who presents to the hospital from jail in active opioid withdrawal, requesting treatment for OUD. She is started on sublingual Bup/nx. As most jails in KY do not provide medications for OUD (MOUD), she receives Bup-XR on day of discharge. CW follows up 35 days after Bup-XR as an outpatient after release from jail. CW reports no illicit opioid use or opioid withdrawal and is administered a second dose of Bup-XR. Her OUD is in early remission.

Discussion:
When treating patients with OUD, one challenge we face is choosing the right MOUD for each individual patient. Treatment with methadone or buprenorphine can be difficult for patients due to the need for frequent clinic visits, transportation barriers, concerns about stigma, and other challenges. Bup-XR is a monthly subcutaneous injection with no diversion risk. Our case series demonstrates its potential for diverse application for patients facing a variety of barriers to MOUD, including patients with OUD who do not readily have access to MOUD (i.e. if experiencing incarceration, have transportation barriers, or live far from a X-waivered provider), patients with comorbid non-opioid substance use disorder when diversion is a concern. Buprenorphine decreases all-cause mortality in OUD, and Bup-XR demonstrates non-inferior retention in treatment compared to sublingual Bup/nx. Bup-XR is well tolerated with a low side effect profile. It is currently underutilized, mostly due to insurance barriers and providers not offering this option to patients. If preferred, patients can return to the sublingual product.

Conclusion:
Bup-XR is an underutilized treatment option that is a potential treatment path for patients facing barriers to MOUD. With its benefits of once monthly instead of daily dosing, its low side effect profile, and nonexistent diversion risk, providing Bup-XR as a treatment option can decrease health care disparity for patients with OUD.