Rapid Initiation of Extended-Release Buprenorphine—Evidence and Barriers

As the drug supply has evolved during the past decade from heroin to fentanyl, so too have buprenorphine treatment options for opioid use disorder.In addition to sublingual tablets and films, there are now 2 US Food and Drug Administration-approved formulations of subcutaneous injectable extended-release buprenorphine.One product, Sublocade (Indivior Inc), was approved in 2017, and the other, Brixadi (Braeburn Pharmaceuticals Inc), was approved in 2023.Patients who received extended-release buprenorphine in clinical trials were more satisfied with treatment 1 and used less fentanyl 2 compared with participants taking sublingual buprenorphine.However, results on treatment retention have been mixed, [3][4][5] with a recent study 4 finding that receipt of extendedrelease buprenorphine was associated with a higher risk of discontinuation early in treatment.In this issue of JAMA Network Open, Shiwach et al 6 report on an industry-funded, multisite, open-label randomized clinical trial that assessed safety and treatment retention with rapid induction compared with standard induction of Sublocade (extended-release buprenorphine).Participants in the standard induction arm received 7 days or more of sublingual buprenorphine before the first dose of extended-release buprenorphine.Participants in the rapid induction arm received a single dose of 4 mg of sublingual buprenorphine followed 1 hour later by extended-release buprenorphine.Both arms received the second injection of extended-release buprenorphine 1 week after the first injection, a schedule intended to rapidly achieve and maintain adequate plasma buprenorphine concentrations.The standard induction approach followed by the second injection 1 month after the first was recommended in the initial approval of extended-release buprenorphine.The product