Changes to the Opioid Dependence Treatment (ODT) program that came into effect on 1 July 2023 could make long-acting injectable buprenorphine (LAIB) the best option for many people.

Now individuals can access the ODT program from their pharmacist at a fraction of the previous cost, pharmacists should expect an increase in demand for ODT services – whether from those new to the program or private-clinic clients. And this will likely include new demand for LAIB.

A more convenient option

There are several driving factors that could make LAIB a more popular medicine, said PSA Victorian State Manager Jarrod McMaugh MPS.

Firstly, clients with complex arrangements – such as picking up ODT medicines from one pharmacy on weekdays and another on weekends – may need to find a new system.

‘The technical nature of the Pharmaceutical Benefits Scheme (PBS) authority prescriptions means two scripts can’t be issued at once,’ said Mr McMaugh.

With LAIB slashing the number of ODT-related pharmacy visits from up to 30 per month to one, it could be a preferable option for clients in these circumstances.

Secondly, while clients are currently able to access fully funded LAIB at private clinics, general practice surgeries and alcohol and other drug services, this funding arrangement will cease from 1 November 2023.

‘Under the new PBS arrangements, LAIB will only be funded through hospital or community pharmacies,’ he said. ‘Without the ability to provide the service to clients directly, doctors will have to engage pharmacies.’

LAIB could also be suitable for clients who don’t qualify for takeaway doses of methadone or buprenorphine films, including those who are:

• just starting the ODT program
• at risk of diversion from the intended use of ODT medicines
• living in a jurisdiction that doesn’t allow takeaway doses when young children live in the household.

Regulations around ODT supply

All jurisdictions technically allow pharmacists to administer LAIB to clients, albeit under different regulations.

While some jurisdictions allow pharmacists to administer any prescribed medicines, others prohibit administration of any injectable medicine by pharmacists unless they have the required training.  

For example, pharmacists in Victoria have been able to administer LAIB to ODT clients since 2021, provided they have undertaken PSA’s Victorian Opioid Pharmacotherapy Program training, while Tasmania has just implemented regulations that include a training requirement. 

‘The PSA provides education for pharmacists on LAIB, which includes a consideration of the regulatory requirements in each jurisdiction,’ said Mr McMaugh.

There are two options for pharmacists to provide LAIB, including:

• administering the medicine on site when patients present with a prescription
• entering into an arrangement with prescribers to deliver the medicine to the clinic for administration to the client.

LAIB cannot be supplied to clients directly due to risk of diversion, and subsequent harm if self-administered; if LAIB is injected intravenously, it can lead to significant injury or death. 

However, pharmacists can recoup costs by:

• agreeing on funded arrangements for delivery with the GP clinic or addiction specialist administering the medicine
• levying private delivery charges to the client.

The pros and cons of LAIB

There are numerous benefits of oral and injectable buprenorphine, including:

• a good safety profile, with no option for diversion
• reducing the impact of other opioids, disincentivising use of other opioids on top of the dose.

Along with the convenience factor, reported adverse effects of LAIB are minimal, said Mr McMaugh. ‘It doesn’t make you feel drowsy all day, so it tends to be a fairly elegant solution,’ he said.

However, there are instances where clients have not received the expected benefits from buprenorphine as an injectable, including failure to prevent cravings. While uncommon, this can be mitigated by titrating the dose effectively.

Furthermore, while LAIB is ideal for patients engaged with the ODT program who no longer want to access opioids in an unsafe or unsustainable manner, it may not be suitable for someone accessing the program due to a court order.

In this scenario, patients who are less engaged in the program may benefit from regular contact with their pharmacist via daily or takeaway dosing.

‘While those clients might pharmacologically benefit from the injectable, they will miss out on the social and therapeutic benefits from their relationship with their pharmacist without daily, or regular contact on a weekly basis,’ said Mr McMaugh.

Next steps

There are both weekly and monthly injectable options, with various strengths available in both.

Depending on the clinical setting, clients often start on a lower strength of medicine followed by a review process where they are asked:

• How are you feeling? 
• Is the medicine working for you? 
• Are you experiencing any cravings?

Clients will then either remain on the same dose or titrate up. 

To best monitor clients until they are stable, Mr McMaugh recommends beginning on a weekly dose. ‘From there, a conversion into the monthly dose needed to get the same effect can be done,’ he said.

While switching from buprenorphine films to injections might be straightforward, those transferring from daily methadone may experience some discomfort.

‘Make sure clients are aware they could experience withdrawal symptoms,’ said Mr McMaugh. ‘While the medicine offers greater stability, clients will need to go through a bit of a process to get there.’

For further information on long-acting injectable buprenorphine, pharmacists can:

• refer to PSA’s Administering medicines by injection course
• attend the PSA23 session on Opioid Substitution Therapy.