TREATMENT BY INJECTION: DEALING WITH YOUR OST ONCE A MONTH?
Imagine only having to deal with your Opiate Substitution Therapy (OST) once a month. The Langton Centre in Surry Hills is part of an international trial of a new, long-acting depot buprenorphine product that can be given with a single subcutaneous injection once a month. No more queues, no more dealing with the daily grind.
Professor Nick Lintzeris who heads up Drug Health Services in South East Sydney Local Health District told UN: “This product will totally change the face of OST in Australia. It’s the biggest thing to happen since buprenorphine was introduced here nearly 20 years ago.”
Prof Lintzeris tells us “These monthly injections will not be for everyone. Patients who need regular support and care or take daily mental health medications with their OST may be better off with a closer relationship to their clinic or pharmacy. But for part of the OST community, the choice to be dosed with buprenorphine only once a month will be a very useful and welcome addition to the range of treatments available for opiate use. Once this new product is approved, there will be a freer life waiting for those who want it.”
The idea of only being dosed once a month certainly unlocks those “liquid handcuffs”. You can now take that job that requires travel, be it airline steward or truckie, without worrying about your dose. If you want to go on holidays there is no fussing with takeaway approvals or transfers. You could even go to countries that frown on OST for as long as a month without having to declare any medications. And for those looking towards abstinence, getting out of the habit of daily dosing helps put their drug use “out of sight out of mind”.
It is also possible the monthly injections may become popular in jail settings, solving some of the issues that limit the number of inmates who are granted OST.
The buprenorphine injection has no naloxone added. Those who choose to inject illicit drugs on top of their monthly injection will find it similar to injecting on top of methadone: they will feel a blunted effect but will not go into precipitated withdrawal.
Prof Lintzeris thinks it will still be 12 to 24 months before the product is on the standard menu here. The approval processes are strict - just as we want them to be. There are two companies ‘neck and neck’ in the race to have their product approved in the US, after which we hope they will tackle the Australian regulations.
Neither product has a market name yet, but for trial purposes are known as CAM2038 (from Braeburn Pharmaceuticals and Camurus) and RB6000 (from Indivior, makers of Subutex and Suboxone).
CAM2038 looks to be more flexible with four different dose strengths for either weekly or monthly injections. By contrast, RB6000 comes in only two doses: high (aiming for blockade effects) and low doses with only a monthly option. Unfortunately, it’s not simply a matter of choosing the best fit – as with many innovations one of these product will probably become standard and corner the market.
At this stage both products have had “double blind” tests (where the product is compared to a placebo or active control group of people on sublingual buprenorphine) with good results, although these studies are yet to be published. Langton is currently one of 4 Australian sites trialling CAM2038 as part of a year-long international trial of 20 sites to ensure the product is safe and workable. Professor Lintzeris reports that clinically all is going well with the trial at Langton. The product is easy to use, it’s flexible, no serious side effects and there appears to be high levels of consumer and staff satisfaction with the product.
The new injections bring advantages, but also challenges for its users. For example as we would not handle the product we wouldn’t be able to share with a needy partner or friend or put any aside for a rainy day. We also need to watch out that this new format is an addition and not a replacement to the current OST menu.
Right now, Australians can be prescribed an entire month’s worth of Suboxone film, yet this option is rarely taken up. This may be because few prescribing doctors or people who use drugs are aware of the option. Prof Lintzeris said “We need better continuing education so that doctors are up on new developments in OST.”
Those people prescribed monthly Suboxone often face costs out of proportion with the service they receive. Many pharmacists charging the same for a single monthly box of medication as for monthly daily dosing. “Section 85” prescribing would allow for a PBS listing, allowing users to pay a monthly cost of just over $6.20 for Health Care Card holders and $38.80 for the waged. It is the responsibility of the pharmaceutical company to apply for recategorising, however we are still waiting.
An additional reason few doctors write monthly prescriptions of Suboxone lies in stigma and discrimination. Doctors often do not trust their patients with a month of medication, believing it may be diverted or lost.
Monthly injections may solve some of these issues - but not if the cost is that we lose other choices. The control we gain by being free from day to day dosing hassles must be weighed carefully against the lack of control we lose by not being able to manage our medication ourselves. And because we are all different, with different needs, any new modes of OST must be additions and not replacements to the status quo. We will always welcome another option to the menu of treatment services.