Can a monthly injection be the key to curbing addiction? These experts say yes.

Andrew Herring has a clear goal walking into every appointment with patients seeking medication to treat an opioid use disorder: persuade them to get an injection of extended-release buprenorphine.

At his addiction clinic at Highland Hospital, a bustling public facility in the heart of Oakland, Calif., Herring promotes administering a shot of buprenorphine in the belly to provide a month of addiction treatment rather than prescribing oral versions that must be taken daily. For him, the shots’ longer-acting protection is a “game changer” and may be his only chance to help a vulnerable patient at risk of overdose.

“At any point in time, they’re just a balloon that’s going to go,” Herring said. “You might only have this one interaction. And the question is, how powerful can you make it?”

Addiction experts say administering a month’s worth of anti-addiction medication holds great potential, particularly for people without housing or who struggle with other forms of instability. Yet despite its promise, the use of injectable buprenorphine remains fairly limited, especially compared with other forms of addiction medication.

Jeanmarie Perrone, the director of the division of medical toxicology and addiction medicine initiatives at the University of Pennsylvania’s department of emergency medicine, said that there’s high demand for Sublocade among patients with addiction. But just a small percentage of Philadelphians on buprenorphine, she estimates, are using Sublocade.

“Patients do really want it — it is very desirable, but it is harder to access,” she said.

Buprenorphine, one of three medications approved in the U.S. to treat opioid use disorder, works by binding to opioid receptors in the brain and reducing cravings and withdrawal symptoms. And because it occupies those receptor sites, buprenorphine keeps other opioids from binding and ensures that if a patient takes a high dose of a drug like heroin or fentanyl, they are less likely to overdose. Patients often stay on buprenorphine for years.

If Herring prescribes a supply of buprenorphine as a tablet or film that is placed under the tongue, the patient must commit to taking the medication at least once a day, and many fall out of treatment. He said this is especially true for his patients experiencing homelessness and those who also use methamphetamine.

Oral forms of buprenorphine have been available to treat addiction since 2002 and can be purchased as a generic for less than $100 a month. Injectable buprenorphine, sold under the brand name Sublocade, received FDA approval in 2017. It has a hefty list price of $1,829.05 for a monthly injection. The drugmaker Indivior reported $244 million in revenue from Sublocade last year alone, with a company goal to eventually make $1 billion in annual sales. No generic or competing version of the drug is available.

Most patients won’t pay full price, Indivior says, because most health plans cover the drug. Physicians, however, say the high cost can be a barrier for patients with private health plans, which sometimes resist covering the medication.

Still, addiction experts say, Sublocade use remains limited in part because of the regulatory hurdles required to dispense it.

Providers must register with the U.S. Drug Enforcement Administration and obtain a waiver to prescribe buprenorphine because it’s considered a controlled substance. In addition, clinics must complete an FDA safety certification program to dispense the medication. And Sublocade can be ordered only by a specialty pharmacy, or at medical practices that have in-house pharmacies, which must also pass the FDA program.

“The primary care offices that initiate Sublocade have to order it a week in advance, and assign it to a single patient — if a patient misses that appointment, it’s potentially going to waste,” said Penn’s Perrone. “You can’t just give it to the next person who shows up and wants it.”

Oral buprenorphine, by contrast, is a simple prescription that most local drugstores keep in stock.

Penn Medicine patients have participated in trials of a seven-day formulation that is injected subcutaneously instead of intramuscularly, as Sublocade is, which could help eliminate another barrier that keeps patients from Sublocade, Perrone said: Intramuscular injections are much more painful.

Making long-acting opioid addiction treatment medications available at regular pharmacies might also help improve the drug’s uptake.

“It’s definitely a lot better for the patient, and the patients know that it helps them help themselves. The ways to make it easier are to have it be dispensed not in a specialty pharmacy — and to have it on demand, rather than preordered,” she said.

Several clinicians noted that access remains a problem even with oral forms of buprenorphine. Despite a cascade of studies proving the effectiveness of medication-assisted treatment, many patients across the country struggle to find a provider willing to prescribe buprenorphine in any form — especially in communities of color.

“The most important question isn’t whether long-acting injectable bupe is a better solution than sublingual buprenorphine for opioid use disorder,” said Michael Ostacher, a professor at Stanford University School of Medicine, who is comparing injectable and oral versions of buprenorphine through Veterans Affairs. “The bigger question is how we increase access to treatment for all people who need [the medication].”

Angela Griffiths is among the patients who say Sublocade has changed their lives. Griffiths, 41, of San Francisco, used heroin for 18 years. When she was pregnant with her daughter in 2016, doctors put her on methadone, which made her feel “miserable.” Three years ago, she said, she switched to buprenorphine films, but carrying the strips with her everywhere still made her feel tied to her addiction.

“The ritual of taking something every day plays something in your mind,” Griffiths said.

When doctors at the San Francisco General clinic switched her to monthly Sublocade injections, she described the change as “extraordinary.”

“I’m not reaching for my drawer anymore for a fix,” she said. “I have the freedom to wake up and start my day however I want, whether it’s to go to the patio and drink a cup of coffee or to snuggle with my daughter in bed a little longer. It’s there; I don’t have to take anything.”

Herring sees urgency — and opportunity — to increase the use of injectable buprenorphine as fentanyl use rises. For years, the deadly synthetic opioid was concentrated mostly on the East Coast; in 2018, 88% of deaths from synthetic opioids occurred in the 28 states east of the Mississippi River. In Philadelphia, experts say it’s in the vast majority of the street drugs involved in fatal overdoses. But more recently, fentanyl has begun to infiltrate Western states. From 2018 to 2020, deaths from fentanyl overdoses in California quintupled, according to state data.

“No one understands what they’re dealing with,” Herring said of fentanyl’s potency. “This is the time where our greatest deaths are going to occur.”

Inquirer staff writer Aubrey Whelan contributed to this article, which is part of a partnership that includes Kaiser Health News (KHN), a national newsroom that produces in-depth journalism about health issues.