The four thin, tiny white rods look like nothing special. But they could be powerful allies for individuals recovering from dependence on opioids.

The rods, each about the size of a matchstick, are part of the first implantable system for delivering consistent, low doses of buprenorphine, a drug used for maintenance treatment of opioid dependence, and naloxone, which prevents narcotic overdose. The Food and Drug Administration approved the implant, called Probuphine, in late May.

University of Colorado Hospital is among the first in Colorado to offer Probuphine. In a one-day training session last June in Albuquerque, Patricia Pade, MD, learned to implant the device just below the skin in a patient’s upper arm. Pade received a special Drug Enforcement Agency number required to perform the office-based procedure.

The implant is another addiction-treatment tool for Pade, who practices at UCH’s Center for Dependency, Addiction and Rehabilitation (CeDAR), directs the University of Colorado’s Addiction Medicine Fellowship Program and leads an addiction medicine consult service at UCH. She also heads a consult service for chronic pain patients at moderate to high risk of addiction to prescribed opioid medications.

Pade hasn’t implanted Probuphine in a patient yet. “In Albuquerque we practiced on pork loins,” she quipped. But she’s optimistic that the device will help some patients ease their transition from dependence to recovery.
Physicians implant the rods in the upper arm in an office-based procedure.

A measured response

“The beauty of the medication is that it delivers to the bloodstream 8 milligrams of buprenorphine every day,” Pade said. Patients receive the measured dose for six months, at which point a physician removes the Probuphine. If it’s necessary, the physician can repeat the procedure in the other arm, she said.

An implant relieves the patient of remembering to take Suboxone tablets, which also combine buprenorphine and naloxone, Pade said. “That’s very good for individuals who are older or worried about their cognitive status, or people who don’t want the hassle of having to remember to take pills,” she said. Individuals who are incarcerated, live in remote areas or travel out of the country might also benefit from an implant, she said.

Implanting medications in a patient’s arm doesn’t eliminate the possibility of drug diversion, but it obviously lowers the risk dramatically.

“It’s certainly harder to divert; there is a much higher threshold than there is with oral medications,” said Steve Millette, CeDAR’s executive director.

Seeking stability

The buprenorphine delivered by the Probuphine implant is itself a narcotic. But Pade emphasized it does not get patients high. Rather, it helps people control their cravings and regain a measure of stability in their lives.

Nor is maintenance therapy an end in itself, Millette added. Rather, it’s a potential bridge to recovery. “The medicine helps people become more functional and learn how to live with the addiction,” he said. “It’s a movement in the direction of greater health.”

For example, patients freed of the obsession with getting the next opioid dose for their chronic pain might turn instead to physical therapy, mindfulness, meditation or other non-drug treatments, Millette said. “The implant isn’t a one-trick pony. It’s another tool in the kit.”

Those in the addiction treatment field are grateful to have another option to offer the growing number of patients battling opioid-related substance use disorders, said Alexis Carrington, MD. Carrington started an addiction medicine fellowship at CeDAR in July.

“There are only a few medications we have to rely on,” Carrington said. The FDA’s approval of Probuphine, she added, “is a sign of how serious the problem is.”

Carrington, who will receive the Probuphine training along with her addiction medicine fellowship colleague Ryan Jackman, MD, noted that the upper-arm implant is discreetly placed and produces minimal scarring. That’s important for more than cosmetic reasons.

Medical maintenance

One of the challenges of prescribing maintenance therapy, Millette explained, is that halfway houses and sober living facilities traditionally have not accepted patients who are taking the medications, partially because they want to avoid monitoring patients for drug diversion. He believes Probuphine will solve that concern while also shifting these facilities’ long-held belief that recovery requires total abstinence from drugs.

“Patients on maintenance therapy can become more independent and function in spite of their conditions,” Millette said. “That helps to make it all the more evident that addiction is a chronic disease and reduces the stigma surrounding it.”

The Probuphine implant is not for everyone, Pade said. “It’s not appropriate for patients who require higher doses of medication to control their craving and pain,” she said.

That still will leave a sizable group of patients who could benefit from the implant, said Millette, who envisions CeDAR taking a leadership role in studying the new treatment’s effectiveness.

“It’s our intention to lead the field in bringing the service into our comprehensive model of care,” he said. “Some people believe that taking medications means not getting sober. We will have a population of patients to evaluate, study and learn from, and we have a willingness to find out.”