and have used it as the missing link to their recovery .
They ’ ve moved on with their lives . One week after their first injection , they turn up , some having already re-engaged with their families , got back to work , got on with their lives . That persists over the months they are on it . Our fear of bringing out their past traumas – given trauma is the gateway drug , with them self-medicating with heroin and then developing maladaptive coping strategies – have proven unfounded .
About half just move on , able to just live their lives again . Of the remainder , about two thirds need to have here-and-now psychological support as past traumas / current issues surface – ably provided by the drug service workers in the coming year as Wales rolls out traumafocused training for all workers . About 10 per cent need more psychological support . Crucially , though , they have reduced craving , reduced anxiety and therefore have the energy and capacity to engage with that support in a timely way .
What has been your experience of implementing Buvidal in your service ? We initially thought it would be fantastic for the pandemic – we asked both English and Welsh governments to fund it during that period and the Welsh Government stepped up to the plate – the roll-out across Wales has been fantastic . It ’ s easiest to summarise in the feedback we get week in and week out – 19 out of 19 nurses we surveyed who had seen it in use wanted to continue using it , the receptionists love it as patients turn up happy , on time and even phone if they ’ re running late for whatever reason .
There was , because of the pandemic , a flexibility in the bureaucracies to support service development at pace . So we implemented fast and developed how we gave Buvidal faster than similar developments in the past – it took years to move out of the shadow of slow-motion starts for oral buprenorphine 20 years ago and we ’ ve done similar in less than a year . Although there will always
be resistance to new things and practices in services , once staff saw the dramatic changes in people they ’ d long given up on they were equally enthused .
What learning would you share with others who are considering prescribing long-acting injectable buprenorphine ? Just do it . Get commissioners to fund ten – it can be in the homeless services , primary care , prison releases . Make sure you measure how well they are before starting – quality of life , attendance records , A & E records , engagement with work or family and so on . Measure those again on Buvidal . You should see four in five make improvements , with the majority being significant . Commissioners like engagement figures so note that they attend every injection .
Figure out how to run their appointments alongside their injections as there is a risk they will not turn up for appointments outside of that time . Not for the reasons we automatically assume with oral opioids – assuming the worst . instead they miss those appointments as they ’ re well , getting on with their lives , working , engaging with their families , and don ’ t need to see anyone .
It ’ s easy to use – a small injection of 0.5ml given subcutaneously . If an old consultant psychiatrist like myself can do it , anyone can . We ’ ve developed and evolved the practicalities so now we start people on either a weekly dose of 24mg – equivalent to around 16mg of oral – 20-30 minutes after a trial dose of 4mg of oral buprenorphine , so they ’ ve come in on the usual withdrawal for that , or have a twoday oral buprenorphine dosing of 8mg daily . Then straight to monthly 96mg , also equivalent to around 16mg oral . For the ones that start at weekly 24mg , we then offer a monthly dose the week after of 96mg or 128mg .
What are your views on the cost of long-acting injectable buprenorphine ? It is roughly £ 200 more annually than oral buprenorphine so this isn ’ t actually an issue , especially as Dame Carol Black ’ s report notes how much , when untreated , opioid users can cost the government per year . Confusion arises as commissioners sometimes forget to include the dispensing and other fees commercial pharmacies get for giving methadone and buprenorphine . Unfortunately , those dispensing fees are sometimes hidden in other budgets or given to commercial pharmacies as a difficult-to-disentangle block grant . So commissioners forget this extra £ 1,000 that is added to the cost of oral buprenorphine annually and fear the cost of Buvidal as it ’ s ‘ much more expensive ’. I don ’ t think £ 200 per year more is that much more expensive , do you ?
How do you see the future of long-acting injectable buprenorphine in services ? Massively expanding – we didn ’ t expect it to be this good , this life changing and this effective .
Inclusion is running an innovative pilot in partnership with HMP Chelmsford to facilitate a smooth prescribing transition for people being discharged from prison to local drug and alcohol services . We asked Kevin Malone , public health programme manager in Thurrock and commissioner of the local Inclusion drug and alcohol service , for his thoughts on the pilot .
A true game changer which will see services pivot from ‘ script and chaos management ’ to finally having the capacity to help these people move on from having made the mistake of self-medicating to deal with their childhood traumas and being stuck with that mistake for decades . It ’ s wonderful to see them suddenly getting back to swimming in the sea of life after so much time simply spent in a daily drowning as they worried about how long they had before they needed their next dose of daily opioid .
I suspect we , in the UK , are at the forefront of seeing the changes as we ’ ve given Buvidal to patients due to the pandemic rather than the select few already stable on oral buprenorphine . I think its remarkable action – the reduction in craving and anxiety and the return of normality – is , in part , due to novel allostatic pharmacology , with us finally seeing kappa antagonism , but that ’ s another story !
What are your hopes for the Buvidal pilot happening across Inclusion Thurrock and HMP Chelmsford ?
My hopes for the Buvidal pilot are positive . For the right client , can we provide a solution that better meets their needs , mitigates the risk of relapse and breaks the cycle of recidivism ? It may not be the solution for everyone , but the broader the range of support available , the more choice we can offer our diverse treatment population . The main legwork with this intervention is ensuring that preparation takes place prior to release , not just for the client but for the range of multi-agency staff that need to play their part in the community , however large or small that role is in supporting the client . I shall have a keen eye on future evaluation data for what is an interesting and exciting opportunity .
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MARCH 2022 • DRINK AND DRUGS NEWS • 11