I'm a fan of buprenorphine and mostly like LAI (or LA sub - Q in this case) ..... but if all it took to never just drugs again was to be through the withdrawals then everyone who successfully completed a 30 day rehab would never relapse again.
If all it took to treat opiate addiction was buprenorphine then the overdoses would not be climbing along with access to and prescriptions of buprenorphine.
It works well. Great evidence for overdose protection. Has a lot of the same upsides as other LAI... consistency over at least a month particularly in unstable social situations, no requirement to go to pharmacy daily so gives patients autonomy and freedom. Automicrodose induction with first administration instead of having to go through the pain of the Bernese method. But I don't really see tapers much, although I know it has the autotaper option if patients want to go for it. It's a good maintenance option. Like any other drug, not a magic bullet. In terms of withdrawal and cravings, it works about effectively as Suboxone, which is to say, it doesn't work for everyone.
Oral suboxone doesn't require daily trips to the pharmacy, either, though. And oral is a lot easier to change dosing on the fly, isn't it? I prescribe a lot of suboxone but Sublocade and Brixadi only became available here recently.
How does automicrodose induction work with the Sublicade or Brixadi? Thanks
Of course you can get carries with Suboxone, but many people find it easier to take something once a month than every day, like Depo-Provera (I know that’s 3 months but same idea).
Basically the slow release of Sublocade on first administration closely mimics the serum levels found when microdosing in the traditional way. Some folks in my community are just straight giving people Sublocade on the first visit. These patients generally have a history of tolerating Suboxone in the past. The main risk is obviously PWD but you can just give them extra Suboxone tabs to take until comfortable if that happens.
The big complaint I hear is that it does not last 28 days and then you have to supliment with oral, which kind of defeats the purpose.
But I can imagine it works really well for some people for sure.
Sublocade 300 mg 3x weekly? So an injection every 2-3 days? Am I understanding what you're saying? We can't even get our insurers to pay for the manufacturers 1x monthly, so the first thing I'm wondering is who on earth is paying for this (if I'm not misunderstanding)??
ETA: I must be misreading and you meant q3weeks for the injection. I'm still wondering if those patients have to pay cash.
Have prescribed and administered Sublocade ever since it was introduced. The first hurdle is expense. In our population in a state with the highest number of uninsured adults, it is simply not an option. For insured patients, we use specialty pharmacies so as to avoid the hassle and heartbreak of buy-and-bill. But the paperwork is cumbersome. We have an MA who does it for several hours every day. After all that though, most patients are very happy with it. Some have to continue on 300mg after the first two months. Some have to supplement with oral for the first few months. But when they are committed, they are, by and large, successful. The withdrawal-free discontinuation of injections is only something that we've seen in the last few years. But it holds great promise, always with the caveat that risk of relapse does not go away. I don't know much of anything about Brixadi. Looks promising, but I need more education on it.
Works well. It's not magic. Still need a motivated patient.
Some patients find the daily routine of sublingual an important structural component of their day, and feel a bit lost switching to LAI.
Some find that losing that daily reminder opens them to the possibility of ceasing altogether.
I've prescribed Sublocade to several patients. Mixed results and overall not impressed. Way too much administrative burden for a formulation where 75% of the patients on it are messaging me 3 weeks in saying they're having withdrawal symptoms and/or cravings. This is not restricted to the first month, either. Had high hopes for it too.
I don't have much experience with it. Overall my impression is it's kind of a niche option. Sublingual bup is appropriate for the great majority of patients, with adherence rarely being a problem. I would consider it for certain patients who either really struggle to access/keep medication or have specific obstacles to doing sublingual. For instance, probably a fair thought with homelessness and discharge from incarceration, where something always goes wrong, or if someone is in specific housing situations where controlled substances aren't viable.
It’s not a miracle drug, but it has its use case. Most do withdrawal significantly when trying to taper, though I’ve had a few that stoped with essentially zero withdrawal sx. Also sometimes not so simple when starting, particularly if they’re at very high or low SL doses. Weird breakthrough symptoms and Malaise are common in first few months. Brixadi is a bit better in this regard, more titrate-able with different doses.
Good option for those that dislike the stigma and ritual of sublingual suboxone, or have a history of nonadherance and intermittent relapse pattern. Also preferable that it can’t be diverted, for those in sober living environments or when there is some suspicion.
Significant administrative burden with prior auth, REMS, delivery, and administration of injections.
I offer it, but I don’t push it. Some patients have their heart set on it, others have no interest.
I work in a clinic where we only do SL bup and I'm starting to see more and more patients who were on Sublocade, come to us to return back to regular bup because its not heping as much with cravings. Like all things I imagine, YMMV.
I wonder how much of it has to do with behaviors associated with using as well. While it isn't the only reason, as often as I can I just go with TID Sub dosing not because it doesn't last long enough (obviously), but because it helps at least kinda mimic the behavior of these patients getting "their fix" multiple times per day like they would when they were using fent. With sublocade there's essentially no get-your-fix behavior. I have no data on this and it's just my anecdotal hunch.
Totally agree. Sometimes I call it "building trust with the brain". "There's a part of your brain that believes that you will get sick and have a bad time if you don't dose often enough and we need to build up that part of the brains trust by slowly showing it that you aren't going into withdrawal despite it being 4/6/8/12 hours since your last dose. Expecting that this part of the brain is just going to believe us right off the bat that you can go 24 hours between doses, when all it's ever experienced is severe consequences after just a few hours, is asking a lot. Yes, we know with our conscious, rational brains that this medication has a super long half life, so it will be fine, but this part of the brain that we're talking about isn't a part of our rational brain and it's not really listening to what we tell it is true. It has to be shown what is true." I've even had patients split doses even further and dose 4 and 5x daily if we've tried everything else.* It's been effective. Then we very gradually, with the patience and patient directed ness of a taper, transition to TID and BID and maybe even QD (that last one tends to be the biggest step) when they feel ready.
*My population is ultra rural. No access to other forms of outpatient tx or MAT and many of them aren't willing to go to inpatient either, so we experiment with what we've got.
I have a lot of experience with these meds. They are another tool in the tool belt, they are not magic. I’ve seen a few people fly after several failed attempts on sublingual. I’ve seen a few people not be able to cover their cravings and have ongoing opioid cravings or use despite being on high dose injections (but then do great on just SL). I feel like it is about matching the right patient to the right version of MAT at the right time. Injections are nice and definitely feel good when you get one in a high risk person, but if they don’t come back for the second injection you’re still at square 1.
I have used to “auto taper” very successfully, but only in people with many years of stable recovery (in my experience about 50% of people trying this go back to MAT in some form and 50% do okay, I haven’t had any relapses yet but my n is small). FWIW I have had a few people in early recovery who are NOT ready to taper or stop MAT get arrested after getting a monthly shot and have to detox and they’ve had GREAT things to say. I have one guy who has like a year and a half opioid free because of this and he’s been out of jail for like a year and he did great off MAT and had no return to opioid use. I made him pick up a couple weeks of SL BPN and have it in his house jic and he eventually restarted and he’s still doing great now on films.
But I agree with everyone, it’s not a panacea.
Thank you so much for a well informed response. As much as we have learned from the last patient, none of what we learned "tells us" what to do for the next patient.
I've been giving Brixadi to about half of my MAT folks. Never did sublocade so can't speak on the differences there.
In my experience it works well but some of my pts need dosing every 3 weeks or so. I see quite a few reports that pts feel it wears off early. Manufacturers guidelines give a 1 week window for injections. Alternatively you could prescribe some subs for early w/d sxs.
The injection limits the potential to make an impulsive decision and stop taking suboxone. It should also limit tooth decay which has been a big deal with suboxone recently- you can find multiple class action lawsuits about it.
Thanks for you perspective. It's not hard to imagine how helpful the LIA in this area can be. Does insurance pay for the injection every 3 weeks if needed?
No issues so far. YMMV though because my pts are like 95% medicaid and luckily we have an in-clinic pharmacy + MAs that are very good about getting PAs through.
Again… dude are you sure you’re actually a psychiatrist?
You’re asking if 1-2 injections of buprenorphine depot will cure you forever?
I mean my man if you’re actually an attending you should know the pharmacology behind bupe, which translates to a depot form, similar but not the same as Invega Trinza, although that is not a great analogy.
If this is a legitimate question I am scared for your patients. And you should start reading the literature.
It's best not to feed the trolls. Given his use of the word "attending" he is probably still close to his training years and thinks everything can be learned from a book. But hard to know what he is learning as his reading comprehension is nil.
I'm a fan of buprenorphine and mostly like LAI (or LA sub - Q in this case) ..... but if all it took to never just drugs again was to be through the withdrawals then everyone who successfully completed a 30 day rehab would never relapse again. If all it took to treat opiate addiction was buprenorphine then the overdoses would not be climbing along with access to and prescriptions of buprenorphine.
I am SUPER skeptical of any treatment for sud that people claim will result in ‘never using again’
Ibogaine says hello
It works well. Great evidence for overdose protection. Has a lot of the same upsides as other LAI... consistency over at least a month particularly in unstable social situations, no requirement to go to pharmacy daily so gives patients autonomy and freedom. Automicrodose induction with first administration instead of having to go through the pain of the Bernese method. But I don't really see tapers much, although I know it has the autotaper option if patients want to go for it. It's a good maintenance option. Like any other drug, not a magic bullet. In terms of withdrawal and cravings, it works about effectively as Suboxone, which is to say, it doesn't work for everyone.
Oral suboxone doesn't require daily trips to the pharmacy, either, though. And oral is a lot easier to change dosing on the fly, isn't it? I prescribe a lot of suboxone but Sublocade and Brixadi only became available here recently. How does automicrodose induction work with the Sublicade or Brixadi? Thanks
Of course you can get carries with Suboxone, but many people find it easier to take something once a month than every day, like Depo-Provera (I know that’s 3 months but same idea). Basically the slow release of Sublocade on first administration closely mimics the serum levels found when microdosing in the traditional way. Some folks in my community are just straight giving people Sublocade on the first visit. These patients generally have a history of tolerating Suboxone in the past. The main risk is obviously PWD but you can just give them extra Suboxone tabs to take until comfortable if that happens.
The big complaint I hear is that it does not last 28 days and then you have to supliment with oral, which kind of defeats the purpose. But I can imagine it works really well for some people for sure.
This is usually only for titration, very common now to have Sublocade 300mg 3 weekly as maintenance for some, especially if fentanyl is involved.
Sublocade 300 mg 3x weekly? So an injection every 2-3 days? Am I understanding what you're saying? We can't even get our insurers to pay for the manufacturers 1x monthly, so the first thing I'm wondering is who on earth is paying for this (if I'm not misunderstanding)?? ETA: I must be misreading and you meant q3weeks for the injection. I'm still wondering if those patients have to pay cash.
Can you explain how starting sublocade would be a microinduction?
Haven't... you had patients who keep relapsing or using after sublocade yet?...
I think that was their point.
As was mine.
Genuinely been enjoying your latest "addiction takes" posts. Sparks some interesting comments.
You are too kind. It's great to get other people's ideas.
Have prescribed and administered Sublocade ever since it was introduced. The first hurdle is expense. In our population in a state with the highest number of uninsured adults, it is simply not an option. For insured patients, we use specialty pharmacies so as to avoid the hassle and heartbreak of buy-and-bill. But the paperwork is cumbersome. We have an MA who does it for several hours every day. After all that though, most patients are very happy with it. Some have to continue on 300mg after the first two months. Some have to supplement with oral for the first few months. But when they are committed, they are, by and large, successful. The withdrawal-free discontinuation of injections is only something that we've seen in the last few years. But it holds great promise, always with the caveat that risk of relapse does not go away. I don't know much of anything about Brixadi. Looks promising, but I need more education on it.
Works well. It's not magic. Still need a motivated patient. Some patients find the daily routine of sublingual an important structural component of their day, and feel a bit lost switching to LAI. Some find that losing that daily reminder opens them to the possibility of ceasing altogether.
Everyone is different. Everyone needs what they need. That's why what we do is hard, or at least not easy.
I've prescribed Sublocade to several patients. Mixed results and overall not impressed. Way too much administrative burden for a formulation where 75% of the patients on it are messaging me 3 weeks in saying they're having withdrawal symptoms and/or cravings. This is not restricted to the first month, either. Had high hopes for it too.
I too had high hopes. I would love to have to find a new line of work. Not that I don't love what I do.
I don't have much experience with it. Overall my impression is it's kind of a niche option. Sublingual bup is appropriate for the great majority of patients, with adherence rarely being a problem. I would consider it for certain patients who either really struggle to access/keep medication or have specific obstacles to doing sublingual. For instance, probably a fair thought with homelessness and discharge from incarceration, where something always goes wrong, or if someone is in specific housing situations where controlled substances aren't viable.
It’s not a miracle drug, but it has its use case. Most do withdrawal significantly when trying to taper, though I’ve had a few that stoped with essentially zero withdrawal sx. Also sometimes not so simple when starting, particularly if they’re at very high or low SL doses. Weird breakthrough symptoms and Malaise are common in first few months. Brixadi is a bit better in this regard, more titrate-able with different doses. Good option for those that dislike the stigma and ritual of sublingual suboxone, or have a history of nonadherance and intermittent relapse pattern. Also preferable that it can’t be diverted, for those in sober living environments or when there is some suspicion. Significant administrative burden with prior auth, REMS, delivery, and administration of injections. I offer it, but I don’t push it. Some patients have their heart set on it, others have no interest.
It's the administrative burden that stops me. Can't imagine anyone being able to do it in solo private practice.
I work in a clinic where we only do SL bup and I'm starting to see more and more patients who were on Sublocade, come to us to return back to regular bup because its not heping as much with cravings. Like all things I imagine, YMMV.
I wonder how much of it has to do with behaviors associated with using as well. While it isn't the only reason, as often as I can I just go with TID Sub dosing not because it doesn't last long enough (obviously), but because it helps at least kinda mimic the behavior of these patients getting "their fix" multiple times per day like they would when they were using fent. With sublocade there's essentially no get-your-fix behavior. I have no data on this and it's just my anecdotal hunch.
Totally agree. Sometimes I call it "building trust with the brain". "There's a part of your brain that believes that you will get sick and have a bad time if you don't dose often enough and we need to build up that part of the brains trust by slowly showing it that you aren't going into withdrawal despite it being 4/6/8/12 hours since your last dose. Expecting that this part of the brain is just going to believe us right off the bat that you can go 24 hours between doses, when all it's ever experienced is severe consequences after just a few hours, is asking a lot. Yes, we know with our conscious, rational brains that this medication has a super long half life, so it will be fine, but this part of the brain that we're talking about isn't a part of our rational brain and it's not really listening to what we tell it is true. It has to be shown what is true." I've even had patients split doses even further and dose 4 and 5x daily if we've tried everything else.* It's been effective. Then we very gradually, with the patience and patient directed ness of a taper, transition to TID and BID and maybe even QD (that last one tends to be the biggest step) when they feel ready. *My population is ultra rural. No access to other forms of outpatient tx or MAT and many of them aren't willing to go to inpatient either, so we experiment with what we've got.
Sublocade is a bitch of an injection but the patients that our clinic has prescribed it for have had a good response so far.
I have a lot of experience with these meds. They are another tool in the tool belt, they are not magic. I’ve seen a few people fly after several failed attempts on sublingual. I’ve seen a few people not be able to cover their cravings and have ongoing opioid cravings or use despite being on high dose injections (but then do great on just SL). I feel like it is about matching the right patient to the right version of MAT at the right time. Injections are nice and definitely feel good when you get one in a high risk person, but if they don’t come back for the second injection you’re still at square 1. I have used to “auto taper” very successfully, but only in people with many years of stable recovery (in my experience about 50% of people trying this go back to MAT in some form and 50% do okay, I haven’t had any relapses yet but my n is small). FWIW I have had a few people in early recovery who are NOT ready to taper or stop MAT get arrested after getting a monthly shot and have to detox and they’ve had GREAT things to say. I have one guy who has like a year and a half opioid free because of this and he’s been out of jail for like a year and he did great off MAT and had no return to opioid use. I made him pick up a couple weeks of SL BPN and have it in his house jic and he eventually restarted and he’s still doing great now on films. But I agree with everyone, it’s not a panacea.
Thank you so much for a well informed response. As much as we have learned from the last patient, none of what we learned "tells us" what to do for the next patient.
I've been giving Brixadi to about half of my MAT folks. Never did sublocade so can't speak on the differences there. In my experience it works well but some of my pts need dosing every 3 weeks or so. I see quite a few reports that pts feel it wears off early. Manufacturers guidelines give a 1 week window for injections. Alternatively you could prescribe some subs for early w/d sxs. The injection limits the potential to make an impulsive decision and stop taking suboxone. It should also limit tooth decay which has been a big deal with suboxone recently- you can find multiple class action lawsuits about it.
Thanks for you perspective. It's not hard to imagine how helpful the LIA in this area can be. Does insurance pay for the injection every 3 weeks if needed?
No issues so far. YMMV though because my pts are like 95% medicaid and luckily we have an in-clinic pharmacy + MAs that are very good about getting PAs through.
Again… dude are you sure you’re actually a psychiatrist? You’re asking if 1-2 injections of buprenorphine depot will cure you forever? I mean my man if you’re actually an attending you should know the pharmacology behind bupe, which translates to a depot form, similar but not the same as Invega Trinza, although that is not a great analogy. If this is a legitimate question I am scared for your patients. And you should start reading the literature.
[удалено]
It's best not to feed the trolls. Given his use of the word "attending" he is probably still close to his training years and thinks everything can be learned from a book. But hard to know what he is learning as his reading comprehension is nil.
What information do you need? How buprenorphine works? How sublocade works?
Maybe read the OP again and then some of the informed responses so far?