(23) Needle-Free Lidocaine Administration Before XR-BUP Decreases Patient Perceived Pain Score

Background & Introduction: Extended-release buprenorphine (XR-BUP) is a subcutaneous injectable month-long medication for patients with opioid use disorder (OUD). One challenge with XR-BUP is the pain associated with the injection in >5% of patients. Patients with OUD often receive fewer pain-alleviating interventions in other healthcare settings compared to patients without OUD. Providers at the Center for Dependency, Addiction, and Rehabilitation (CeDAR) were trying to decrease patients’ perceived pain by using common anesthetic tactics before XR-BUP, such as cold therapy, topical lidocaine, and subcutaneous lidocaine injections. Despite these measures, CeDAR patients were still reporting significant pain with XR-BUP. When investigating other pain-alleviating tactics, our team discovered the J-TIP device, a needle-free device that uses pressurized carbon dioxide gas to deliver lidocaine subcutaneously. This device was primarily studied in pediatric patients to decrease pain before needle procedures such as IV starts and venipuncture. No literature was available surrounding the use of subcutaneous lidocaine, administered by injection or by the J-TIP, before XR-BUP. We hypothesized that using the J-TIP to administer lidocaine before XR-BUP could provide decreased pain experiences.

Methods: We developed a standardized process for administering lidocaine with the J-TIP before XR-BUP to patients in the clinic. The inclusion criteria were patients receiving XR-BUP. There were no exclusion criteria. The primary outcome measure was patients’ perceived pain level of XR-BUP without and with a pre-injection administration of lidocaine via the J-TIP. Patients receiving XR-BUP were universally offered pre-injection administration of lidocaine via the J-TIP in addition to other pain-alleviating measures. Patients completed a survey rating their XR-BUP injection pain experience on a scale of 0-10 without and with the pre-injection lidocaine administration. Survey data was collected between January and June 2024. A total of 83 surveys were collected during this time.

This study employed a retrospective pretest-posttest design to evaluate patients' perceptions of pain following an XR-BUP injection with or without lidocaine via the J-TIP device. To account for missing values and maximize the use of available data, a linear mixed-effects model was used to compare pain perceptions between retrospective pretest and post-test measures. Statistical analyses were conducted with the SciPy (v1.14.1) and Statsmodels (v0.14.4) modules implemented in Python 3.12.5.

Results: The linear mixed-effects model demonstrated a significant reduction in mean pain scores between retrospective pre and post-test measures (z = -15.6, p < 0.05). On average, post-test pain scores were estimated to be 4.7 units lower than pre-test scores (95% CI: -5.28 to -4.1).

Conclusion & Discussion: This QI project demonstrated that administering lidocaine via the J-TIP before XR-BUP significantly reduced perceived pain levels for our clinic patients. Once the J-TIP device became available, we began universally offering lidocaine pre-injection for all XR-BUP patients, regardless of whether it was their first injection. This approach aimed to avoid delaying the benefits of potentially reduced pain for patients starting XR-BUP. However, we then asked patients to rate their pain of XR-BUP without and with lidocaine via the J-TIP during the same encounter, so recall bias is a study limitation. Despite limitations such as the study’s retrospective design and the small number of missing values, the results are promising. Future research could evaluate the effects on treatment retention for patients who receive lidocaine via the J-TIP before XR-BUP or directly compare pain levels of XR-BUP if lidocaine is administered via subcutaneous injection or the J-TIP. Ultimately, this intervention has the potential to enhance patient comfort and improve the overall experience of individuals receiving XR-BUP injections.

References: 1. Alford DP, Compton P, Samet JH. Acute pain management for patients receiving maintenance methadone or buprenorphine therapy [published correction appears in Ann Intern Med. 2006 Mar 21;144(6):460]. Ann Intern Med. 2006;144(2):127-134. doi:10.7326/0003-4819-144-2-200601170-00010
2. Indivior Inc. (n.d.). Sublocade prescribing information. https://www.sublocade.com/Content/pdf/prescribing-information.pdf
3. JTIP. What is JTIP? JTIP. Published October 2023. Accessed January 12, 2025. https://jtip.com/what-is-jtip/