Background
Timmins is a northeastern city in Ontario with a population of around 42,000. The pandemic has caused mortality rates related to the opioid crisis to increase significantly.
Emergency doctors Louisa Marion-Bellemare and Julie Samson became frustrated because what they were doing wasn't working. People were coming in experiencing withdrawal and the induction period for sublocade was too long to see success in patients with opioid use disorder. Louisa and Julie knew it was time for a change, and they needed one faster than they could wait for randomized controlled trials.
Opioid Agonist Therapy (OAT)
Opioid agonist therapy (OAT) is an effective treatment for addiction to opioid drugs such as heroin, oxycodone, hydromorphone, and fentanyl. The therapy involves taking the opioid agonists methadone (Methadose) or buprenorphine (Suboxone). These medications work to prevent withdrawal and reduce cravings for opioid drugs. Methadone carries more risk than Suboxone (risk of overdose), which may make Suboxone (bup + naloxone) preferred for some, but not all. Medications used in OAT are long-acting opioids instead of short-acting. By acting slowly, they prevent withdrawal for 24 to 36 hours without making a person to feel high. OAT can be just what someone needs in their unique recovery journey.
Sublocade
Sublocade contains the same opioid agonist as suboxone, buprenorphine, that helps beat opioid addiction by minimizing withdrawal symptoms and ease cravings by blocking the rewarding effects of opioids.
It is also used for the management of moderate to severe opioid use disorder in adults who have been inducted and clinically stabilized on a transmucosal buprenorphine-containing product (equivalent of 8-24 mg/day buprenorphine). This means that there is a minimum 7-day period required before sublocade can be given.
Sublocade is injected as a liquid and then turns to a solid gel in the body, called a depot. This depot gradually releases buprenorphine at a controlled rate all month, so that levels of buprenorphine in the blood remain consistent.
Sublocade is initiated at 300-mg for the first 2 months, and then switched to 100-mg monthly for maintenance. There is the potential to increase it back to 300-mg monthly if the client does not demonstrate satisfactory clinical response to and can tolerate the 100-mg dose.
Sublocade Versus Suboxone
There are some key differences between these drugs in terms of their content, route, frequency, and induction. See the table below:
Taking Action
Louisa and Julie knew this induction period was too long as they witnessed patients leave before they could receive the injection. They were also curious as to why they couldn't give sublocade after days 1-3 if tolerating high dose suboxone. The biggest risks involved are precipitated withdrawal (PW) and side effects. The PW is due to the high affinity of buprenorphine (partial opioid agonists) for the mu receptor in the body.
Lousia and Julie began to investigate. They found 2 small studies, which were unpublished at the time, regarding the evidence for early sublocade administration. If you are interested in viewing them, search up:
‘SUBLOCADE Rapid Initiation Study’
'An Open-Label Pilot Study of Sublocade as Treatment for Opiate Use Disorder’
Both doctors felt that because studies were happening and not being stopped because of something going wrong, why not try it? What else could go wrong when things were this bad?
Macrodosing became a game changer. They presented their initial findings at the 2021 META:PHI CONFERENCE. META:PHI is a provincial initiative to support health care providers in treating people struggling with substance use disorders.
Timmins and District Hospital (TADH) began rapid induction with suboxone, by increasing to 32 mg on day 1 (within 3 hours). Administration of sublocade 300 mg was being given in just 24-72 hours. Patients were being discharged after being given the injection with community follow-up. Between Dec. 7, 2020-July 31, 2021, 70 doses were given.
Louisa and Julie also decided to give injections as early as 14-days apart as opposed to 26 in those that began to experience cravings again. Additionally, they keep patients on the 300-mg of sublocade monthly for at least the first 6 months, as they found that around 90% would destabilize when they dropped down to 100 mg so early. No adverse events were seen other than nausea and constipation.
Response
Giving the extended-release injection has resulted in satisfied patients and healthcare workers. Anecdotally, Dr. Samson believes there to be over 70% retention to the program.
As results are continued to be analyzed, we must be ready to implement changes as soon as we can in other cities. Not only can it improve quality of life for patients and prolong life, but treating substance use disorder in a medical sense helps change the culture in healthcare regarding how we treat those with addiction. We would never turn away someone having a heart attack from the emergency department, so why is it acceptable to do so when someone has substance use disorder?
We have got a long way to go, but with passionate people like Louisa and Julia working to improve our response to the opioid crisis. there is hope.
References
Centre for Addiction and Mental Health. (2016). Opioid agonist therapy. Retrieved from https://www.camh.ca/-/media/files/oat-info-for-clients.pdf
Fookes, C. (2022). Sublocade vs suboxone: What's the difference between them? Retrieved from https://www.drugs.com/medical-answers/difference-between-sublocade-suboxone-3535227/
INDIVIOR. (n.d.). Sublocade. Retrieved from https://www.sublocade.com/
Marion-Bellemare, L., & Samson, J. (2021, September 24). Desperate times call for desperate measures: Breaking the barrier for treatment of OUD using macrodosing & depot buprenorphine. META:PHI Conference 2021 [Virtual].
Purdon, N., & Palleja, L. (2022). How two doctors are changing the rules in the fight against opioid addiction. CBC News. Retrieved from https://www.cbc.ca/news/health/opioids-timmins-treatment-program-outreach-1.6279543
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