In the United States, opioid-related overdose deaths steadily increased for two decades, to 81,806 in 2022. However, this number fell in 2023 to 79,358, due to the implementation of various strategies and interventions, including increased access to buprenorphine. [1]
How buprenorphine treatment is beating opioid addiction
Buprenorphine is one of the most effective medicinal treatments for managing opioid addiction, or opioid use disorder (OUD), and various administration and treatment methods are being developed and used. [2]
For example, one option is to initiate the individual on a very low dose of buprenorphine while they continue to use the addictive opioid, gradually increasing and reducing these doses respectively. This helps to reduce withdrawal symptoms while buprenorphine levels increase. [3]
Another protocol involves stopping the opioid and waiting for withdrawal symptoms to start before initiating a high dose of buprenorphine. Both options can be effective when implemented in inpatient settings but are less successful in outpatient services, due to difficulties tolerating withdrawal and complex dosing schedules. [2][4]
New protocol and its effectiveness
A new protocol has been developed, an injectable-only overlapping buprenorphine protocol, referred to also as direct-to-inject buprenorphine initiation. This involves the administration of three long-acting buprenorphine injections over three days. On day one, 8 mg is administered, which works over one week; on day two, another weekly dose of 16 mg is administered; and on day three, a dose of 128 mg or 300 mg lasting one month is administered. [2]
Three-quarters of people involved in the study completed the three-day treatment administration, and 64% returned one month later for a second monthly injection. Initial study results show promising success with reductions and cessation of fentanyl. Withdrawal symptoms were minimal, as the medication is released slowly. [2][5]
Although this protocol shows some limitations, this method is quick and easy to administer, reduces the risk of withdrawal, and implements a maintenance dose within a short time, which can make it a successful treatment in both inpatient and outpatient settings. [2][5]
Other factors reducing opioid overdoses
In response to the opioid overdose crisis, national and state policies and strategies have been implemented. For example: [6][7]
- Community education: Communities have been provided with education programs to help increase understanding of the risks of opioid use, overdose prevention, and harm reduction strategies.
- Prescriber education: Healthcare providers have learned different strategies for chronic pain management to reduce prescription numbers and duration.
- Prescription policies: Policies around opioid prescriptions have changed, including limiting prescriptions and checking prescription drug monitoring programs (PDMPs) before providing opioid treatment.
- Naloxone policies and access: Many communities have improved access to and education around the use of naloxone, with prescription naloxone given to high-risk patients and “Good Samaritan” legal protection for individuals to carry and administer naloxone if required.
Barriers to accessing buprenorphine & who is affected
Although access to treatments and buprenorphine prescriptions is improving, many people still face barriers to treatment, including: [6][7]
- Prescription costs or limited insurance coverage
- Difficulties accessing treatment when homeless or experiencing housing issues
- Lack of education or understanding of the available treatments
- Inability to attend clinics or treatment centers due to issues with travel, time, or finances
- Issues with pharmacies filling prescriptions
Telemedicine can help people access treatment who face barriers, and allows providers to prescribe buprenorphine through video or audio appointments. However, this can result in issues relating to prescription filling.
One study investigated barriers faced by 601 people utilizing telemedicine for OUD. Almost one-third of these individuals were unable to fill their prescription at a pharmacy at least once in the last 12 months, with a quarter of these going seven or more days without buprenorphine. The most common issues experienced were: [8]
- Pharmacies had low stock and had to order more
- Pharmacists were hesitant or unwilling to fill prescriptions made by telemedicine
- Pharmacists were suspicious of potential diversion attempts
- Pharmacists were unwilling to fill a prescription written by clinicians from another state
This hesitance among pharmacists is largely due to regulatory scrutiny from enforcement agencies and company policies designed to prevent diversion and fraudulent prescriptions.
Is buprenorphine treatment guaranteed to help overcome opioid addiction?
No treatment is guaranteed to help overcome opioid addiction, and the success of a treatment can depend on many factors. However, buprenorphine is one of the most effective treatments for OUD, and buprenorphine maintenance treatment is associated with a 50% reduction in overdose mortality. [2]
Key factors impacting the success of buprenorphine in OUD treatment include low rates of treatment initiation and retention, which can be due to: [2][3][4]
- Fear of withdrawal symptoms when commencing treatment
- Barriers to accessing clinics, treatment centers, or prescriptions
- Confusion or intolerance to complex dosing schedules
- Lack of professional monitoring and support when provided through outpatient services
Other promising opioid use disorder treatments
OUD treatment can include a range of treatment approaches, including: [9]
- Other withdrawal or maintenance medications, such as methadone and naltrexone
- Symptom management medications such as clonidine, tizanidine, NSAIDs, and loperamide
- Therapies and behavioral interventions such as cognitive behavioral therapy (CBT), motivational interviewing, and contingency management
New approaches to OUD treatment are continually being investigated, with various interventions showing promising potential and necessitating further research. For example: [10][11]
- Psychedelic substances such as MDMA, psilocybin, and ketamine
- Neuroimmune modulatory approaches such as N-Acetylcysteine and ceftriaxone
- Neuromodulatory interventions such as deep brain stimulation (DBS) and transcranial magnetic stimulation (TMS)
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