Kristina Beladi, FNP, started in 2017 as a community health primary care provider with a significant MOUD population, then transitioned to inpatient substance use treatment and outpatient private practice primary care. In 2023, she left primary care and began doing solely substance use treatment. She is currently the Medical Director at Avalon Counseling Services in Lewiston, where she provides outpatient substance use and mental health treatment in a collaborative treatment model with therapists. She continues to work at Liberty Bay Recovery Center, providing medical care for a continuum of withdrawal management, residential, PHP, and IOP
How long have you been incorporating long-acting injectables into your practice? What initially motivated you to start using XR injectables?
I started using Vivitrol (XR naltrexone) in 2017 when I started as a nurse practitioner, as it significantly increased patient stability. I started using extended-release (XR) buprenorphine in 2023 in an inpatient setting, where I found that patients were more likely to stay in recovery after discharge if they were started on long-acting medication prior to discharge. In 2024, I joined Avalon Counseling Services, an outpatient substance use and mental health treatment center that had never had an in-person medical provider. We immediately started using injectables as there was patient demand, and they aid in patient retention.
What have you found to be the key benefits and challenges of using long-acting injectables with your patients?
One of the benefits as a prescriber to using XR buprenorphine is that it significantly reduces the risk of misuse and diversion. For patients who are homeless, actively using, or have limited resources, etc., it allows them to maintain treatment even if they can’t keep their medications safe or come in the office as consistently. There are also patients who have found it helpful in their efforts to taper off buprenorphine.
Some of the challenges are coordinating and tracking the delivery of injectables. It requires significant administrative support to ensure we have all of the injections when patients are due, and at times, this can be a last-minute, chaotic effort despite best efforts/intentions. Additionally, when patients are lost to care, we often have to destroy medications, and then don’t have them when patients return to services. Some patients also continue to have withdrawal symptoms between doses despite multiple doses and reducing dose intervals, which requires SL bridging and significant coordination of care with patients when this arises. Furthermore, XR buprenorphine requires prior authorizations, which is an administrative burden.
In what ways are you currently administering these injectables (e.g., in-office, via pharmacy, mobile units, etc.)?
Currently, I administer almost all injectables in the office myself. We typically utilize Genoa as we are a MaineCare-only practice, and they coordinate and deliver efficiently to our office. I can receive most injectables within 2 days of writing the script. Other insurances require specific specialty pharmacies, which often have a significantly longer turnover process and multiple calls to insurance companies to get PAs to go through and delivery coordination. Shaw’s Osco pharmacies also support injectables by pharmacists on site. Prescriptions are sent to the Dover Foxcroft location specifying the location for administration, and Dover Foxcroft distributes to that location. For initial injections, the turnover can be approx. 1 week and can require multiple contacts. Follow-up injections are coordinated and tracked by Shaws’ Osco.
There is also an option to buy and bill injectables, where the office has the injectables billed to them, and then, after administration, it is billed to the insurance and reimbursed. This does reduce the administrative burden of coordinating the above, but requires significant up-front cost. This does allow reduced destruction of medication as it can be held in the office longer vs. patient-specific buprenorphine, per DEA guidelines, which has to be destroyed 45 days after receipt.
From your perspective, what are the main advantages and disadvantages of partnering with a pharmacy for administration?
One of the benefits of using a pharmacist to administer injectables is that it reduces the administrative burden of coordinating delivery/administration. It can also expand catchment areas as patients can be farther away geographically and still maintain care and can increase access for patients in rural areas.
Disadvantages include potentially reduced in-person contact with patients as the in-office injection is often the only time patients present in person. At times, coordinating with pharmacy administration can slow down the process of initiating injectables, and pharmacies may have different protocols of administration than patients could get in-office (e.g., ice as procedural anesthesia vs. topical or injectable lidocaine, or only offering specific injection sites).
What advice would you give to other prescribers who are interested in working with a pharmacy to administer extended-release buprenorphine?
Have dedicated staff with protocols for follow-up on prior authorizations and pharmacy administration. This often requires multiple follow-up calls/contacts to ensure that patients receive their injections. Reassure patients that their local pharmacy will not see the prescription until after it has been routed by Dover-Foxcroft to the local pharmacy, which can take several days. Encourage patients to be in close contact with the office and ensure you receive documentation of administration.
What are the lessons you learned?
Whether XR buprenorphine is administered in-office or through a pharmacy, there are multiple administrative steps required to coordinate. However, from my perspective, there is significantly increased patient stability, retention, and reduced risk in the community, which can far outweigh the administrative challenges if appropriately supported.