(86) Inpatient Initiation of Long-Acting Injectable Buprenorphine: A Case Series

Background & Introduction: Buprenorphine is a highly effective treatment for opioid use disorder (OUD). Many patients, however, struggle with adherence to sublingual buprenorphine (SL-BUP) due to barriers such as unstable housing, lack of transportation to appointments, comorbid chronic illnesses and easy access to heroin in their communities. Among efforts to reduce barriers to treatment, research has shown that inpatient and emergency department initiation of buprenorphine are promising sites of intervention, yet follow-up rates after discharge remain low. Long-acting injectable buprenorphine (LAIB) has the potential to address some of these barriers and improve engagement in care but has typically only been available in the outpatient setting. Based on prior research, patients seen by our Addiction Medicine Consult service between 2020-2022 and started on SL-BUP in the hospital had follow-up rates after discharge between 22-26%. In this case series, we report on our experience with an initiative to initiate LAIB in hospitalized patients.

Methods: Data were abstracted from the electronic medical records (EMR) of forty-six patients who received LAIB while hospitalized, between August 4 and December 28, 2022. For the data abstraction, both a procedure manual describing each variable and where to find the data in the EMR, and a standardized abstraction form were created. A random sample of six charts were abstracted by two separate data abstractors to assess inter-rater reliability. Four general buprenorphine induction strategies were used in this study to transition patients to LAIB, 1) low-dose SL-BUP, 2) low-dose intravenous buprenorphine, 3) standard SL-BUP, 4) high-dose SL-BUP. All patients received LAIB as part of treatment initiation. Descriptive statistics were used to summarize population characteristics. Differences between those who attended their follow-up appointment and those who did not attend their follow-up appointment were compared using Fisher’s exact tests for categorical variables and t-tests for continuous variables. Inter-rater reliability was calculated using Cohen’s Kappa. To determine the baseline follow-up rate for inpatients with OUD seen by the addiction medicine consult service in the two years prior to the study dates, we used data maintained by the quality improvement and data analysis team at the outpatient addiction medicine clinic.

Results: The average age of the patients in our study was 57 (SD +/- 9), and 42 (91%) identified as Black. 39 (86.7%) patients had Medicaid insurance. The majority 41 (89%) of patients self-reported intranasal heroin use, with 37 (80%) of patients reporting exclusive intranasal use.
Four patients received LAIB on the first day they started either IV or SL-BUP (day zero). Fourteen (14) patients received LAIB on day one, 14 on day two and 14 after 3 or more days. For the majority of patients, we used a low-dose buprenorphine initiation protocol, either sublingual with only two cases of precipitated withdrawal during the initiation process with SL-BUP and no cases of precipitated withdrawal after the administration of LAIB. 26 (56.5%) of the patients in our study who received LAIB in the hospital attended a hospital follow-up appointment after hospital discharge. In the 21 months before the study dates, 22% of patients with OUD who were seen by the addiction medicine consult service in the hospital attended a follow-up appointment in the outpatient clinic within six months. 22 (48%) patients received more than one LAIB injection after discharge. Kappa for the follow-up outcome was 0.67 indicating substantial agreement between the abstractors.

Conclusion & Discussion: Administering LAIB to hospitalized patients is feasible and can be done rapidly, with only two episodes of precipitated withdrawal during buprenorphine induction prior to LAIB administration and no episodes after LAIB administration. Most patients received LAIB as part of a low-dose buprenorphine initiation protocol. A greater proportion of patients who received LAIB during their hospitalization attended their outpatient follow-up appointment compared to baseline. The improved follow-up after LAIB suggests that hospital administration of LAIB could play an important role in retention in care after hospital discharge but needs further study.

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Ganetsky, V.S., Salzman, M., Carroll, G., Heil, J., Sutton, J., Visioli, V.M., Currie, S., Schmidt, R., Baston, K.E., Haroz, R. (2023). Hospital-Initiated Extended-Release Injectable Buprenorphine Using a Novel Reallocation Initiative from an Outpatient Addiction Medicine Clinic. Journal of Addiction Medicine, 17(1), 108–110. doi: 10.1097/adm.0000000000001038 23;17(4):485-487. doi:10.1097/adm.0000000000001148

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