In 2017, the United States Department of Health and Human Services declared a public emergency, stating that there was an opioid crisis. From 2010 to 2018, there was a 120% increase in opioid deaths across the US. One of reasons has been the over-prescription of opioids for chronic pain management, another is the increase in more potent and toxic opioids.
Buprenorphine is also an opioid but can be used to treat opioid addiction. It reduces the severity of withdrawal symptoms and competes with other opioids for opioid receptors. While it produces some euphoric effects, these are less intense than those caused by other opioids.
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The Opioid Crisis in California
The opioid crisis in California was sparked by the overprescribing of opioid drugs and the illicit use of heroin and fentanyl. Most people who are addicted to heroin begin with taking prescription opioids. Deaths related to opioid overdoses have been rising year by year. In 2016, just under 2,000 people died from opioids, whereas in 2020, over 5,000 people died. Of these deaths, 3,946 related to fentanyl.
Fentanyl is a very potent opioid, about fifty times more potent than heroin and about one hundred times more potent than morphine. Just 2 mg of fentanyl has the potential to cause a fatal overdose. The Drug Enforcement Administration (DEA) reported that four out of ten pills contain at least 2 mg of fentanyl. Often heroin or other opioids will be mixed with fentanyl and the user does not know that they are taking it.
What is Buprenorphine?
Buprenorphine is a partial agonist of opioid receptors. It is used to treat opioid use disorders and acute and chronic pain. It can be taken under the tongue, in the cheek, as a skin patch, as an implant, or by injection. In the first few days of withdrawal, buprenorphine is commonly combined with naloxone to relieve withdrawal symptoms. It is taken when withdrawal symptoms start as it can cause worse symptoms if taken too early due to displacing other opioids from receptors.
After detoxing from opioids and no longer experiencing acute withdrawal symptoms, some people experience post-acute withdrawal symptoms which include anxiety, depression, and drug cravings. Buprenorphine can help at this stage by reducing cravings and the chance of overdosing if someone does relapse. It keeps other opioids from binding, so if a high dose of heroin or fentanyl is taken, it will not have the same effect.
Side effects of buprenorphine are similar to those of other opioids including nausea, vomiting, memory loss, and headache. If you stop taking it, you may experience withdrawal symptoms such as stomach cramps, restlessness, sweating, irritability, insomnia, vomiting, and diarrhea. It is therefore recommended to stop taking buprenorphine gradually under the supervision of a doctor.
The Benefits of Injectable Buprenorphine
A study by Haight and colleagues showed that participants who received injections for six months were more likely to have 80% of the weeks in the study opioid-free compared to 2% for the placebo. People who completed the study also reported that they had experienced increased employment. It is thought that the effects of injectable and oral buprenorphine are the same, however, it is less likely that people continue taking the pills.
Buprenorphine has been available as an oral pill to be taken daily for the treatment of opioid use disorders for twenty years. However, taking buprenorphine daily can be difficult. People often stay on buprenorphine for years, so taking a pill every day can be hard to maintain, making them feel like they are bound to their addiction even during recovery. Injectable buprenorphine could be a better solution. It involves one injection into the stomach each month which releases buprenorphine slowly into the body. Health experts have seen that this is particularly good for those without housing or other forms of instability and for those who use methamphetamine as well as opioids.
There is evidence that one-third of people with oral buprenorphine subscriptions misuse their medication. Injectable buprenorphine could reduce this risk as they are not given pills to be taken over an extended period which can be taken in a higher quantity early in the month. Since injections must be administered by a medical professional, it is not possible to take more than the prescribed dose unless they buy additional buprenorphine from the street.
Downsides of Injectable Buprenorphine
Despite evidence that injectable buprenorphine could help with long-term recovery for opioid use disorders, there are barriers to accessing it. One of these barriers is the high price. Buprenorphine pills can be acquired for less than $100 per month. However, one injection of the drug costs almost $2000. Currently there is no competing version of the drug, with only Indivior’s Sublocade approved by the FDA. While Indivior has stated that most health plans cover the drug, people with private health plans may not be able to access it as private health care providers often resist including it in their plans.
There are also hurdles in terms of distribution. To dispense injectable buprenorphine, a person must be registered with the US Drug Enforcement Administration and complete an FDA safety certification program. This means that there are limited places where people can access the drug. By contrast, oral buprenorphine is a simple prescription that most pharmacies stock, though there have been reports that pharmacies are reluctant to fill a prescription, especially in communities of color.
Getting access to injectable buprenorphine covered by health insurance can take months as it can require prior authorization. Even without this wait, it can take months to get an injection due to a lack of availability and pharmacy delays. This very much depends on the pharmacy and doctor. Some have a network which allows quick administration, for example, having the pharmacy in close quarters to the doctor, but this is a rarity.
Final Word
As with other addiction services, there are many more hoops for people to jump through when they have an addiction rather than other diseases. While injectable buprenorphine could help with California’s opioid crisis, it will need to become more accessible both in terms of location, waiting times, and price. It is all too common that those struggling with substance use disorders are not given the support they need.
