We looked into this in 2000 when data-2000 was being debated. What we found was virtually no support for it within the key bodies necessary to make it happen, including the addiction scientists.
One of the reasons the sublingual formulation was developed was because of its slow onset. As you may know drugs that have slow onsets to their effects have a lower addiction potential than drugs that reach the brain faster. In a typical sample of pain patients (or the general population) only about 10% of people who take pain medication chronically become addicted to the medication, meaning they develop the uncontrollable dangerous compulsive behavior and lose control over their drug intake. However 100% the addicted population is made up from this 10%, so anyone receiving addiction treatment is at a higher risk of addiction than the average population. Injectable buprenorphine was thought to have too high of an addictive potential itself to be effective in treating addiction, due to its fast onset, when compared with the sublingual formulation. The initial “rush” after the injection is too similar to drugs of abuse to allow the brain to make the necessary adaptations back to addiction free life. Although I agree this is better than nothing in those countries where the sublingual formulation or methadone isn’t available, the hyper sensitive anti-drug coalition would not have allowed it to be used to treat addiction in this country. It seems they are more interested in protecting people from treatment medications than from addiction.
Others noted that the reconditioning of the brain necessary for sustained addiction remission would be hampered with daily injections since this more closely resembled addictive behavior, and could be reinforcing rather than reconditioning. The increased feeling of reward from the faster onset of the injectable formulation, could potentially keep the addiction active, although it would be much safer to the patient than using street drugs.
I can only see injectable buprenorphine being used in the future, at least in the US , if the onset could be slowed and if like Vivitrol, it could be formulated into a monthly injection. Titan pharma has developed a subcutaneous buprenorphine rod that lasts for 6 months.
Although I agree that no medication should be off limits to doctors and Buprenex should be available to doctors, as you mentioned, the current climate in the US (FDA, NIDA, DEA) makes it unlikely.
I disagree with your premises that the sublingual formulation of buprenorphine is only harm reduction, although I agree that the injectable formulation would be. Patients taking sublingual buprenorphine are able to stop their addictive behavior (not continue it with a safer legal medication) Once stable, the dangerous compulsion to take drugs is gone, patients regain control over drug use, missed days at work decrease, spread of HIV -HEP-C decrease, virtually all of the hallmarks of addiction disappear. This drastic change in behavior has a physical affect on the brain and actually allows a “rewiring”, reversing some of the changes caused by addiction. With successful behavior modification during the treatment period most patients will be able to make sufficient brain adaptations to transition off the medication and keep the addiction in remission with cognitive tools only. This is not a solely a harm reduction strategy, it is effective treatment.
Also patients with very high dependencies, like the ones you described, may not be able to get enough agonist effect from any dose of buprenorphine and will require the full agonist methadone. Patients unwilling to take bupe may find the methadone more acceptable since it is a full agonist. I don’t see where a patient who is unwilling to take a full agonist like methadone, would be willing to take an injection of a partial agonist, unless it producing a "rush" and in that case would be detrimental to sustained remission. Until a longer acting formulation of buprenorphine is available, I think the sublingual formulations of buprenorphine, and oral methadone can treat the majority of patients seeking help.
Lastly, many US physicians are undereducated when it comes to treating addiction. Despite knowing it is a chronic condition many don’t treat it like one, by offering 5 day treatments, or even UROD. I think part of the government’s resistance to approve any treatment medication stems form this lack of consistency and knowledge of modern addiction treatments. The current treatments are often administered improperly. We think education is the key to more treatment availability. For example, the FDA is reviewing and expected to approve an injectable depot version of naltrexone that last for 30 days for the treatment of opioid addiction (or opioid dependence as they term it). Naltrexone implants have been cut out by patients, who cannot tolerate the months of post acute withdrawal. If this drug is administered to patients too soon in their treatment it could cause people to start abusing non-opioid drugs like cocaine or methamphetamines, of which there is no medical treatment, or even cause some to succumb to the associated depression and commit suicide. Education must be the priority so potentially good treatments don’t become banned because of the consequences when used improperly. I'm sorry we can't get behind using injectable buprenorphine to treat addiction.
im sure that would help people's situations. A world where anybody could just go get their pure meth, pcp,and heroin wouldnt be a world for very long....
