Real-world Administration of Extended-release Buprenorphine Suggests That Deviation From Standard Dosing is Common

The recommended administration of extended-release buprenorphine (BUP-ER) to treat opioid use disorder is 300 mg/month for two months followed by 100 mg/month after stabilization on transmucosal buprenorphine for ≥7 days. However, little is known about real-world use. Researchers performed a population-based cohort study characterizing BUP-ER administration among 2366 adults residing in Ontario, Canada who had outpatient BUP-ER initiations between 2020 and 2022. Patients were considered to have continuous treatment if BUP-ER was refilled within 56 days and were censored if they switched to a different opioid agonist treatment, died, or reached the maximum follow-up date.

• The median time to BUP-ER discontinuation was 183 days, with 30 percent retention at 365 days.
• Over half (52 percent) of the cohort received 300 mg for ≥3 injections, and 19 percent only received 300 mg injections.
• Among those who did reduce to 100 mg, 29 percent of the cohort had a subsequent increase back to 300 mg.
• Over half (52 percent) of the cohort continued transmucosal buprenorphine-naloxone after BUP-ER initiation.

Comments: This study provides evidence that real-world administration of BUP-ER often deviates from the manufacturer’s recommendations, suggesting possible inadequacy of the standard protocol for many patients. Despite adjustments, >70 percent of patients who initiated BUP-ER discontinued it within the year, although one-third subsequently re-initiated. It is not clear how provider practices (e.g., lack of dose adjustments or transmucosal supplementation), patient characteristics (e.g., fentanyl exposure), or other factors influence discontinuation or deviation from the standard protocol.

Brigid Adviento, MD, MPH* & Darius A. Rastegar, MD

* 2023–24 Rich Saitz Editorial Intern & Addiction Medicine Fellow, University of Iowa Hospitals and Clinics

Reference: Iacono A, Wang T, Tadrous M, et al. Characteristics, treatment patterns and retention with extended-release subcutaneous buprenorphine for opioid use disorder: A population-based cohort study in Ontario, Canada. Drug Alcohol Depend. 2024;254:111032.