Throughout the state of California, opioid overdoses and related deaths are on the rise. In 2020, the California Overdose Dashboard reported the total number of overdose-related hospital visits at 16,537 and deaths at 5,502.
Buprenorphine has a long history of success in opioid inpatient rehab, alike as a key player in many people’s recovery from this devastating addiction. A new spin on the old medication, now offered as an injection, may help providers deliver treatment to the hardest-to-reach.
Opioids in California: The State of Affairs
Experts largely attribute the shifts in overdose rates in the past few years to the pandemic-related mental health crisis and the now widespread saturation of fentanyl in the California opioid (and to a lesser extent, stimulant) market. While these factors are difficult to study independently on this timescale, there is plenty of reason to believe the one hand, beginning in 2020, pandemic-induced job loss, economic uncertainty, and social ills suffered by mobilizing policy tools such as stay-at-home directives exacerbated the experience of many mental health conditions, substance use disorders included. At the same time, those who were already in care or seeking care for existing opioid addictions will have faced notable challenges in accessing and continuing care as in-person treatment was largely interrupted during this time.
Then, there is fentanyl. Overdoses involving fentanyl, the most potent opioid currently available on the market and a substance that is now frequently used to cut lower-potency street drugs, increased by 365% between the first quarter of 2019 and the third quarter of 2021 according to the DHCS. These numbers are deeply significant to the state’s addiction-related health crisis – fentanyl is now implicated in over 70% of overdose deaths in the region.
Even though fentanyl has become commonplace in illegal markets for opioids as a mode of cheapening production for the highest highs, most users are not able to predict what the potency of the substances they opt to use will be. Just a few grains more or less can produce a vastly different dose of narcotic in the nervous system. The uncertainty increased by the widespread cutting of street drugs with fentanyl has been a game changer and a profound threat to the lives of users.
Buprenorphine: How It Works
Many Californians who struggle with opioid addiction also face considerable additional stability challenges, such as difficulty finding or maintaining housing or work – challenges that make scheduling and planning the long-term and life-saving care necessary for opioid addiction difficult to access. Buprenorphine injection, a treatment that has solid evidence for treating or staving off patterns of opioid abuse, may be one piece of the puzzle for treating these individuals.
Buprenorphine, one of only three medications that have been approved by the FDA to treat opioid addiction, has been used in clinical settings for over 40 years. It is a ‘partial opioid agonist’, meaning it is a compound that acts on the same neurons in our brains that opioids do. It activates the same processes but to a much lower effect. It sits on the neuron and stays there for a prolonged period – conveniently occupying any stronger opioid’s seat should the addicted patient relapse, and ultimately keeping dangerous overdose symptoms at bay.
It also significantly reduces cravings and alleviates the acute symptoms of opioid withdrawal. Over time, it can be used to slowly wean individuals off of the higher doses and physical dependence on narcotics that make these addictions so hard to kick. Detailing its uses for opioid addiction treatment, the Substance Abuse and Mental Health Services Administration summarizes that it can:
- Diminish the effects of physical dependence on opioids, such as withdrawal symptoms and cravings
- Increase safety in cases of overdose
- Lower the potential for misuse
The Injection Method: Shifting Treatment for Shifting Times
Historically, buprenorphine has been administered in pill form, as a part of a high-engagement long-term addiction treatment plan. It requires a high degree of commitment from users in treatment when taken as a tablet. The patient needs to take it a minimum of once a day, often for years. This commitment is less complex for individuals in residential care, those with stable schedules and consistent storage, and those who can easily schedule their lives around regular and frequent outpatient clinic visits, but this doesn’t match the profile of everyone in need of treatment.
Buprenorphine injection offers a different promise. This method uses the same medication, but when it is administered through a syringe by a medical professional, it only requires once-a-month doses for the same action in the nervous system. Struggling users need only make one hospital visit for a month of protection against overdose and relapse, making injection a potent development in the battle against rising addiction.
Between client visits at his addiction clinic in Highland Hospital, Dr. Andrew Herring, Attending Emergency Physician and Associate Director of Research at Highland Hospital-Alameda Health System, has been working hard to advocate for the efficacy of buprenorphine injection for individuals struggling with opioid addiction.
Sensitive to the diverse needs of his clients, Herring states “It’s like a religious thing — you have to wake up every morning and repeat your vows… In reality, there are a lot of people who deserve treatment who can’t meet that requirement.”
Persistent Barriers
For the time being, buprenorphine injection remains underutilized. Pharmacies and clinics alike need to complete an FDA safety certification before they can legally dispense or administer this medication. This means that it is largely only available at specialty providers and pharmacies. As a controlled substance, providers need to register with the US Drug Enforcement Administration to acquire a waiver before they can prescribe it. These factors delay the process of accessing care from weeks to months and the hoops involved lead to many providers opting out.
However, most health plans do cover this medication. Medi-Cal, the statewide health insurance program for low-income individuals, does cover Sublocade (buprenorphine’s shelf brand name) without prior authorization.
That said, times are changing and there seems to be a space for buprenorphine to deliver treatment to many who have found it hard to reach. With more and more doctors and hospitals coming on board, Herring’s words may encapsulate a new era of treatment: “You might only have this one interaction. And the question is, how powerful can you make it?”
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