Medical director`s refrain to patients: `I don`t want to go to your funeral`

As potentially deadly as today's opioid problem is, it makes sense to have as many treatment options available as possible. The medical director at the Mountainside facility in Canaan, Conn., is enthusiastic about now being able to offer the first approved monthly injectable formulation of buprenorphine to opioid-dependent patients—even if in some cases it might take hours to secure insurance's OK for a patient to receive the new option.

“It's an arduous process right now with commercial insurers,” Randall Dwenger, MD, tells Addiction Professional. “But quite frankly, it's worth it. To save a life, it's well worth spending four to six hours on the phone.”

Dwenger says that his center, which offers several levels of care and already was using sublingual daily buprenorphine and monthly injectable naltrexone (Vivitrol) in its programs, has so far been able to offer around a dozen patients the injectable buprenorphine formulation (Sublocade) that received federal approval late last year. While the decision over which medication to use ultimately rests in the partnership between the provider and the patient, Dwenger says monthly injectables such as Sublocade by definition offer additional protections against the insidious nature of opioid addiction and relapse.

“There is added value to the injectable—they're blocked for a month,” says Dwenger. “This is a disease that tells you that you don't have a disease. With the sublingual drug, you can take two days off from taking the medication and you can go back to using. You can't do that with Sublocade.”

Dwenger adds, “More and more as providers we have to be thinking, 'How can I block your opioid receptors?'”

The gravity of the message he tries to communicate to patients often takes the form of, “I don't want to go to your funeral.”

Working with insurance

Dwenger says that in these early months of Sublocade's availability, state-funded insurance in Connecticut is ahead of the private market in its responsiveness to the new option.

“The injectable buprenorphine is so new that a lot of the [private] insurers don't have it on their formularies,” he says. “I'm hoping that maybe it's easier after Jan. 1,” with the start of a new plan year.

He sees numerous ideal candidates for the injectable formulation over sublingual buprenorphine, including individuals who have had multiple treatment exposures and/or have not fared well under usual care.

Buprenorphine in either a daily or monthly dosing can be easier to initiate than injectable naltrexone, Dwenger says, because it is often difficult for individuals with an opioid use disorder to meet the requirement that they be opioid-free for around 10 days before they can start taking injectable naltrexone.

Dwenger says the feedback he has received from patients helps tell him that Mountainside is on the right track in having the new monthly buprenorphine option available. They'll make comments such as, “It just takes cravings off the table, so now I can work on me,” he says. Medication-assisted treatment (MAT) thus becomes an essential tool for allowing the rest of the essential work in treatment to proceed, he says.

“More and more we have to realize that MAT isn't a possible option. It's the standard of care,” Dwenger says.