How the Pandemic Affects Treatment for Veterans with Substance Use Disorders
Clinicians treating substance use disorder patients at the VA have faced a specific dilemma during the COVID-19 pandemic: How to deal with veterans who need to receive monthly injections at clinics and VAMCs as a critical component of their therapy. Making the choices even more difficult is recent research showing that injectables significantly extend time to relapse for those patients.
SEATTLE — As states and VA facilities move out of lockdown and resume more non-COVID-related activities, physicians are reassessing the best way to treat substance use disorders in the short term and in the event of a second wave.
Many veterans receive monthly injections as a critical component of their therapy for substance use disorder, but as many clinics and hospitals closed this spring, they were often switched to oral medications that they could self-administer.
That decision was taken on an individual basis for the most part, as the VA had no national policy in place in the early stage of the pandemic to guide care teams, said Andrew J. Saxon, MD, director of the Center of Excellence in Substance Addiction Treatment and Education, VA Puget Sound Health Care System, and professor in the Department of psychiatry and Behavioral Health at the University of Washington School of Medicine, both in Seattle.
“For injection medications, it comes down to a decision about each individual patient whether bringing a patient in with some exposure [to COVID-19] gives them more benefit than self-administering medication during a pandemic,” Saxon told U.S. Medicine.
Factors to consider include the patient’s mode of transportation—public conveyance or private vehicle, whether they live in a group home, or work in a setting that would increase their exposure and, therefore, the risk to healthcare providers.
“Bringing a patient in for an injection is a moment of increased risk of transmission of COVID-19 and we want to avoid every instance of increased risk we can,” Saxon noted. Still, “if personal protective equipment is available for the provider and to protect the patient, the risk of infection is very small.”
Alcohol Use Disorder
The opioid antagonist naltrexone is approved in both oral and injection formulations for alcohol use disorder. The oral form must be taken daily; the injection lasts a month.
Randomized clinical trials that have compared the injectable to the oral version in alcohol use disorder have had mixed results.
A recent retrospective review undertaken at the VA, however, found that long-acting injectable naltrexone tripled the median time to relapse in veterans with alcohol use disorder from 50.5 days for oral naltrexone to more than 150 days.1 The researchers concluded that long-acting injectable naltrexone should be considered the first-line option for these patients, though they called for larger randomized controlled studies to confirm their results.
The study authors noted that the lifetime prevalence of alcohol use disorder is 42.2% in veterans and 39% of patients who seek treatment discontinue their medication and relapse.
The findings match up with what Saxon has seen in practice.
“The clinical experience is that for patients who have a hard time taking oral medications or don’t get as good a response, the injection is better,” Saxon explained.
Injectables have two significant advantages. “The obvious one is that the patient doesn’t have to worry about taking medications on a daily basis,” he said. “The pharmacokinetic reason is that injectables provide a steady blood plasma level and, therefore, patients experience a more stable brain level that with transmucosal or oral formulations that have peaks and valleys.”
Those factors may contribute to better outcomes for veterans. “We certainly see some patients that respond better to injectables, with better trajectories for recovery from alcohol use disorder,” Saxon said.
Opioid Use Disorder
The calculation is a little different for patients on injectable medications for opioid use disorder.
“You’ll want to continue injectables if a patient is on them for opioid use disorder even during this time because they have been shown to be more effective” than oral medications, Saxon pointed out.
A randomized controlled trial has demonstrated superiority of injectable naltrexone to the oral formulation for those with opioid addiction.2 Patients receiving the long-acting naltrexone injection have also already gone through a detox period of at least seven days.
Another mainstay of opioid therapy, buprenorphine, is also available as an injectable that lasts 30 days. The pivotal randomized controlled trial (RCT) for that injectable compared it to placebo rather than the commonly used sublingual formulation which combines buprenorphine with naloxone to minimize its potential for abuse.
A second buprenorphine injectable for opioid use disorder will come on the market in December. Made by the same company that produces the buprenorphine implant, it will provide both seven-day and 30-day options. The RCT on which the U.S. Food and Drug Administration relied for approval of the new drug found it superior to sublingual buprenorphine, Saxon noted.
The pandemic has disrupted both care for current patients with substance use disorders, as well as research into the best options for their ongoing treatment.
Saxon noted with disappointment that the VA had just funded an RCT comparing long-acting injectable buprenorphine to daily sublingual buprenorphine that has been put on pause. The trial is expected to enroll 900 veterans over a three-year period. Participants in the VA-BRAVE study will be actively followed for 52 weeks to assess any differences in retaining veterans in opioid treatment and in sustaining opioid abstinence.
“It takes three years or more to plan these large studies. It’s frustrating to apply the brakes when we’re on the verge of starting a really major study, but we’re on hold now because of the pandemic,” Saxon said.
The pandemic has not blocked patients who need injections from receiving them at the VA Puget Sound, though.
“We’ve had very good results with 30 patients who are doing very well on injections and most have decided to continue them through the pandemic,” said Saxon. “Our brave and heroic staff want to take care of our patients and our nurses are willing to give patients these injections.”
- Leighty AE, Ansara ED. Treatment outcomes of long-acting injectable naltrexone versus oral naltrexone in alcohol use disorder in veterans. Ment Health Clin. 2019;9(6):392‐396. Published 2019 Nov 27. doi:10.9740/mhc.2019.11.392
- Sullivan MA, Bisaga A, Pavlicova M, et al. A Randomized Trial Comparing Extended-Release Injectable Suspension and Oral Naltrexone, Both Combined With Behavioral Therapy, for the Treatment of Opioid Use Disorder. Am J Psychiatry. 2019;176(2):129‐137. doi:10.1176/appi.ajp.2018.17070732