For patients undergoing opioid dependence treatment (ODT), long-acting injectable buprenorphine (LAIB) can be a life-changing treatment option.
Since 2020, demand for LAIB has steadily increased, replacing older ODT therapies such as methadone, said John Jones MPS, who administers LAIB at his pharmacy in Shortland, New South Wales.
‘THE National Opioid Drug Therapy Statistics Annual Data Collection shows that there is a “There has been a significant growth trend in this area,” he said.
But with changes to the ODT scheme coming into effect on 1 July 2023 – including new provisions in the Pharmaceutical Benefits Scheme (PBS) allowing only LAIB to be funded by hospital or community pharmacies – pharmacists are likely to be administering the lion’s share.
To help pharmacists meet this demand, Australian Pharmacist examines the pros and cons of LAIB administration for patients and pharmacists, as well as the intricacies of running an effective LAIB clinic.
What are the main advantages of LAIB?
To access most ODT therapies, such as methadone or sublingual films of buprenorphine and naloxone, patients must see their community pharmacist up to 30 times per month.
But LAIB’s longer dosing intervals means that patients must present a lot less often – allowing them to fulfil their professional or parental responsibilities, or even go on holiday.
LAIB is a stable and predictable drug, with drug withdrawal This discontinuation has been reported to be associated with less severe symptoms than discontinuation of other ODT medications such as sublingual buprenorphine or methadone.
“The risk of diversion is also much lower and it allows our patients to lead more normal lives,” Mr Jones said.
The way LAIB is administered also places it in perfect alignment with other therapies administered in a community pharmacy.
“Patients let pharmacy assistants know they’re there for their injection, and then they sit and wait,” he said. “The medication is administered in a private space so patients can receive any injection, which helps remove some of the stigma associated with other forms of opioid substitution.”
LAIB administration can also mean less paperwork for pharmacists. “You don’t have to sign off on doses every day like you do with oral forms,” he said.
However, LAIB patient visits can take longer. “Because of the longer period between doses, more information needs to be gathered than in a daily appointment, particularly to establish the patient’s stability,” Jones said.
Circumstances can also change over the course of a month, particularly due to a deterioration in mental health. “Pharmacists should then contact their healthcare team to inform them of what has happened.”
What LAIB options are available?
There is three LAIB products currently available on the PBS list under Section 100 of the Opioid Addiction Act:
- Buvidal weekly (5 to 9 day program)
- Buvidal monthly (3-5 week program)
- Sublet (Schedule 26 to 42 days).
“Sublocade has a longer dosing interval … so it may be a better option for patients who are flying in,” Jones said. “And the the expiration date at room temperature has just been extended from 1 to 3 months”.’
“But it’s a more difficult dose to administer than Buvidal because it is much thicker, the volume is greater and the needle gauge is also larger, so all these factors must be taken into account.
Who is a good candidate for LAIB?
Patients whose work/life commitments don’t fit with regular dosing would be good candidates for LAIB, Jones said.
“Although initiation takes a little work, it eliminates the need to be there every day for dosing,” he said.
Patients who are stable on sublingual films of buprenorphine and naloxoneand some patients on methadone, Amay be transferred to LAIB. Appropriate clinical guidelines should be followed carefully.
According to Mr Jones, all pharmacies are well placed to administer LAIB – provided they have a trained vaccinator on staff (read APArticle from 2023 for a detailed explanation of state and territory regulations regarding the administration of the LAIB).
“This is a very different type of opioid substitution therapy than they’re used to, and the demographics of the patients also tend to be different,” he said. “These patients are managing their opioid addiction, and they’re typically working and caring for their children and/or family.”
What do pharmacists need to know?
For those interested in starting a LAIB clinic, Jones recommends approaching it like any other professional service, such as vaccination.
“Workflow, inventory, legislation and booking system needs all need to be considered,” he said.
“You can basically piggyback on other services by creating a new element called ‘LAIB injections’ and filling in the blanks around it.”
But because LAIB must be injected subcutaneously, with the risk of serious harm if injected incorrectly, some patients should be avoided by less experienced pharmacists, at least initially.
“With very lean patients, it’s hard to find enough fat to inject,” he said. “For example, Buvidal should be injected at a 90 degree angle, so in thinner patients this could mean it goes straight into their muscle.
Although administration technique evolves with expertise, which can be aided by obtaining a few demonstration devices from the manufacturer, Jones recommends choosing your patient’s demographics carefully from the beginning. “Anthropometry is important here,” he added.
Communication with the patient about the professional delivery of the service is also important for those who may have apprehensions.
“Having confidence and providing a little more context and structure for patients removes some of the concerns potentially associated with other forms of opioid replacement,” Jones said.
It is essential that LAIB injections are never handled by patients or made directly accessible to patients. Pharmacists should put procedures in place to prevent this, ensuring that injections are never delivered directly to the patient or their caregiver.
What are some useful resources?
Vaccinating pharmacists interested in administering LAIB will be well prepared to do so after attending The tip of LAIB workshop at PSA24, led by Mr. Jones on Sunday August 4 from 1:30 p.m. to 3:30 p.m.
“There will be some demonstrations of LAIB administration, as well as practical examples of how to set up a service, the documentation to be completed and other guidance on policies and procedures to consider and put in place,” he said.
It is also possible to register for a single day at PSA24. But to avoid late fees, it is essential to reserve your place before midnight on July 25. Those who cannot attend the conference can also fill out the PSA form Administration of long-acting injectable buprenorphine (LAIB) by pharmacists course.