Extended-Release Buprenorphine: Pearls, Protocols and Possibilities from 3000 Injections

There are many potential advantages for utilizing extended-release buprenorphine rather than sublingual formulations in patients with opioid use disorder. Such advantages include improved adherence and less diversion. However, there are many potential barriers to patients obtaining this often very effective treatment. Some may include costs, logistical issues, or insurance coverage. In addition, this medication has only been available for less than four years meaning that many providers have limited clinical experience. There is potential for complications including injection site reactions, patients feeling underdosed, or overdosed. There are many unknowns, including definitive data on how best to address these challenges, how to incorporate serum buprenorphine levels, how to develop novel dosing protocols, and the potential role in specific populations such as pregnancy or those with chronic pain. The three presenters manage over 300 patients on extended-release buprenorphine in their busy addiction medicine practice. With their experiences of over 3000 injections, they will review challenges and provide clear, specific techniques to keep patients engaged in treatment with optimal results. Clinical pearls will be grounded in the literature when available. However, given how nascent extended-release buprenorphine is, published data is exceedingly limited. Off-label successes will be reviewed, but will be clearly delineated as such. Some of the specific issues surrounding extended-release buprenorphine which will be addressed include:● Initiation – choosing the right patients, transitioning from other medication-assisted therapies, insurance pitfalls, and handling common patient concerns● Administration – reviewing proper storage, thaw timing and injection technique, and the use of local anesthesia to minimize discomfort● Timing and dosing – developing administration schedules and dosing that align with each individual patient’s physiology and response, utilizing serum buprenorphine levels, and providing limited supplemental sublingual buprenorphine when appropriate● Complications – Delineating infections and significant adverse events from more common and benign local injection site reactions requiring reassurance● Novel uses – proposing use in (currently off-label) populations such as pregnant people and those with chronic pain● Transitioning – tips on weaning, and how to assist patients who may be leaving your practice and/or area● Innovative settings – consideration for extended-release buprenorphine in prisons, prior to discharge from rehab, and in mobile units will be explored● Future developments - innovations in the pipeline to remove barriers (no refrigeration, increased dosing options, varied injection sites, etc.)