REVIEW OF: Lee JD et al, JAMA Netw Open 2021;4(9):e2123032

STUDY TYPE: Randomized comparative effectiveness trial

When people with opioid use disorder (OUD) are released from incarceration, they have a high risk of overdose—especially if they are not prescribed any medication for OUD. We know that methadone, sublingual buprenorphine/naloxone (SL-Bup), and injectable naltrexone all improve OUD outcomes in this population, but what about the relatively new long-acting injectable buprenorphine (XR-Bup, brand name Sublocade)? In this new study, researchers compared SL-Bup with XR-Bup to assess feasibility of administration and acceptability among people being released from incarceration.

Researchers enrolled 52 incarcerated, soon-to-be-released adults from New York City prisons who were already receiving SL-Bup for OUD. Half were randomized to start XR-Bup in prison with the goal of continuing it in the community. The other participants remained on SL-Bup. All participants were followed for eight weeks post-release. The primary clinical outcome was treatment retention.

The researchers first examined whether it was even feasible to give XR-Bup injections in incarceration settings. They concluded that it was. Most participants (21 of 26) received at least one dose of the medication before release (mean number of doses 2.3). Those on the injection required fewer daily jail clinic visits and had no incidents of diversion (whereas there were two incidents in the SL-Bup group). This led researchers to conclude that starting XR-Bup while incarcerated saves both time and labor.

Several post-release clinical outcomes were also superior in the XR-Bup group as compared to the SL-Bup group. There was a two-fold increase in buprenorphine treatment retention at week eight (69% vs 35%). The average length of time that patients stayed on buprenorphine after release was higher if they were receiving XR-Bup (6.1 weeks vs 2.6 weeks). There were more opioid-free urine tests in the XR-Bup group as compared to the SL-Bup group (55.4% vs 38.5%). No differences in the rates of serious adverse events were observed between the two groups, and no overdoses were observed in study participants.

The researchers did identify a few barriers to XR-Bup, including lack of knowledge about the formulation, perceived lack of access in the community, opposition to needle sticks, and a preference for staying with the familiar SL formulation. At the conclusion of the study, seven XR-Bup participants chose to switch back to SL-Bup, citing injection pain and preference.

Carlat Take

Although these findings are preliminary, and it will likely be some time before it is widely available in prison settings, XR-Bup appears to be a promising intervention for an extremely high-risk population. Expanding access to XR-Bup in the general outpatient setting will also be a critical step in making this intervention feasible.