Depot Decisions: New Study on Patients’ Experiences with Depot Buprenorphine
A new treatment of opioid dependency became available in Australia a few years ago, much to the excitement of clinicians and doctors in this field. It is a long-lasting formulation of buprenorphine, an opioid agonist that effectively reduces cravings, prevents withdrawal symptoms, and has a higher affinity to opioid receptors than heroin and morphine, thereby significantly reducing the full effects of these substances if taken. This formulation is injected into the subcutaneous tissue and can last from one week to six months. Healthcare workers in Australia have been enthusiastically promoting this treatment to their patients because it is more cost-effective than other opioid-agonist therapies, means reduced visits to the chemist and clinic, and often comes with few adverse side effects. As a long-acting therapy, it will help individuals adhere to the treatment program and is simply a different way of receiving a treatment they may already be on (sublingual buprenorphine). Indeed, the research exploring patients’ views on depot buprenorphine suggests that they share healthcare workers’ positive attitude towards this new formulation (Larance et al., 2019; Neale, Tompkins, & Strang, 2019; Tompkins, Neale, & Strang, 2019) and have enhanced health-related outcomes, like improved quality of life, less treatment burden, and significantly less opioid use (Barnett et al., 2021; Lintzeris, 2021; Peckham et al., 2021).
However, there is not much information about what it is like to be on depot buprenorphine, the unique issues individuals on this treatment manage, and why some people decide to stop. A team of researchers at the National Drug & Alcohol Research Centre (NDARC), UNSW Sydney, conducted a study to explore this topic, understand the lived experience of depot buprenorphine treatment, and individuals’ motivations to discontinue. Forty open-ended, semi-structured interviews were conducted with people from six major cities in Australia who had tried this treatment. Twenty-one of these participants were on depot buprenorphine at the time of the interview and nineteen had discontinued or were in the process of discontinuing.
For many participants, being on depot buprenorphine was relatively unproblematic and a generally positive experience overall: they had few adverse side effects, discovered newfound freedom, were able to return to the workforce and no longer felt like they were in treatment for opioid dependency. Not having to go to the chemist daily for dosing was another significant benefit of depot buprenorphine and a major motivator to starting this treatment. This was because people would no longer be bound to pharmacy opening hours and be able to avoid stigmatising treatment when collecting their daily dose. Depot buprenorphine allowed these participants to feel ‘normal’ again; they were able to move forward with their lives and find new ways of being.
This encouraging experience with depot buprenorphine, however, was not shared by all. Several participants developed a range of difficult adverse side-effects that sometimes lasted for months, such as chronic pain in joints, major withdrawal symptoms, significant sleep disturbances, on-going issues with the injection site, and chronic constipation. A few participants with pre-existing health conditions described how they felt like the depot buprenorphine was interacting with their medications and/or exacerbating their conditions. This was especially true for those managing mental health issues. There were others who said this therapy was totally ineffective at curbing cravings and preventing withdrawal symptoms.
It is unsurprising that participants who had a good rapport with their clinic and healthcare team tended to have greater success with the treatment compared to those who had a fraught relationship with them. Members of the latter group often felt unheard or ignored by their healthcare team and had to labour to advocate for themselves. Some of these participants spoke about how they were forced into this treatment, either by not being given any other therapy options or having the decision thrust upon them by their doctor. This not only engendered a sense of distrust and cynicism towards clinicians, but made the participant feel trapped. Furthermore, many participants stated that they were given little-to-no information about depot buprenorphine before they started the treatment. Some used this as an opportunity to seek out information themselves and use this time to carefully consider if they wanted to proceed, whereas others felt clueless as to what they were putting into their body and how it might affect them (which raises significant concerns around informed consent and patient agency).
The reasons why participants decided to discontinue depot buprenorphine were just as diverse as their experiences on this treatment. A handful of participants stopped the program because they felt ‘cured’ and no longer felt the need to continue with it. Others who had a poor reaction to the treatment and experienced overwhelming adverse side-effects or no effect at all did not hesitate to stop. Participants who felt pushed into starting depot buprenorphine and had a poor relationship with their healthcare team were also more likely to discontinue this treatment and either swap to a different form of opioid dependency therapy or drop out of treatment altogether. A concern that many participants shared was how to get off the depot buprenorphine program. They often struggled to get a satisfactory answer from their doctor or were told that it would take up to 18 months to discontinue, and many were fearful about what might happen once they stop.
These experiences paint a rich picture of what it is like to receive depot buprenorphine and the unique issues these patients face. The majority of participants, including some of those who had had a poor experience with the treatment, stated that it is a great option for the right type of person: someone who is keen to remain abstinent, are ready to ‘get serious’ about their treatment, and respond well to the injections. One of the core messages this study tells us is that it is vital for healthcare practitioners to listen to clients, have open and thorough discussions about different treatment options, and to be patient with them. Depot buprenorphine is a promising new treatment for opioid dependency and can be an excellent therapy for some, but it should be considered as one more tool to use rather than the best tool for everyone.
Barnett, A., Savic, M., Lintzeris, N., Bathish, R., Arunogiri, S., Dunlop, A., Haber, P., Graham, R., Hayes, V., & Lubman, D. (2021). Tracing the affordances of long-acting injectable depot buprenorphine: A qualitative study of patients’ experiences in Australia. Drug and Alcohol Dependence, 227, Article number: 108959.
Larance, B., Degenhardt, L., Grebely, J., Nielsen, S., Bruno, R., Dietze, P., Lancaster, K., Larney, S., Santo Jr, T., Shanahan, M., Memdovic, S., Ali, R., & Farrell, M. (2019). Perceptions of extended-release buprenorphine injections for opioid use disorder among people who regularly use opioids in Australia. Addiction, 115, 1295 – 1305.
Lintzeris, N., Dunlop, A., Haber, P., Lubman, D., Graham, R., Hutchinson, S., Arunogiri, S., Hayes, V., Hjelmström, P., Svedberg, A., Peterson, S., & Tiberg, F. (2021). Patient-Reported Outcomes of Treatment of Opioid Dependence With Weekly and Monthly Subcutaneous Depot vs Daily Sublingual Buprenorphine: A Randomized Clinical Trial. Journal of the American Medical Association Network Open, 4(5), Article number: e219041.
Neale, J., Tompkins, C., & Strang, J. (2019). Prolonged-release opioid agonist therapy: qualitative study exploring patients’ views of 1-week, 1-month, and 6-month buprenorphine formulations. Harm Reduction Journal, 16(25), 1 – 9.
Peckham, A., Kehoe, L., Gray, J., & Wakeman, S. (2021). Real-world outcomes with extended-release buprenorphine (XR-BUP) in a low threshold bridge clinic: A retrospective case series. Journal of Substance Abuse Treatment, 126, Article number: 108316.
Tompkins, C., Neale, J., & Strang, J. (2019). Opioid users’ willingness to receive prolonged-release buprenorphine depot injections for opioid use disorder. Journal of Substance Abuse Treatment, 104, 64 – 71.