From the Guidelines
The best approach for transitioning from fentanyl to Sublocade (buprenorphine) is to discontinue fentanyl, wait for the onset of mild to moderate withdrawal symptoms, and then initiate oral buprenorphine induction with a low dose of 2-4mg, titrating up to a stable dose of 8-24mg daily over several days, before administering the first Sublocade injection. This approach is supported by the study 1, which recommends that women abstain from short-acting opioids at least 12-24 hours before induction and long-acting opioids 36-48 hours before induction. The presence of at least mild withdrawal symptoms should be verified by the administration of a validated opioid withdrawal scale.
The transition from fentanyl to Sublocade requires careful management to minimize withdrawal symptoms. The study 1 highlights the challenges of managing patients exposed to xylazine-adulterated opioids, but it does not provide specific guidance on transitioning from fentanyl to Sublocade. However, it emphasizes the importance of careful assessment and management of opioid withdrawal symptoms.
Some key points to consider when transitioning from fentanyl to Sublocade include:
- Discontinuing fentanyl and waiting for the onset of mild to moderate withdrawal symptoms before initiating buprenorphine treatment
- Starting with a low dose of oral buprenorphine (2-4mg) and titrating up to a stable dose of 8-24mg daily over several days
- Continuing oral buprenorphine induction for at least 7 days to ensure stability before administering the first Sublocade injection
- Administering the initial Sublocade dose of 300mg monthly for the first two months, followed by maintenance doses of 100mg or 300mg monthly based on patient response.
This approach is necessary because buprenorphine is a partial opioid agonist with high receptor affinity that can displace full agonists like fentanyl from receptors, potentially precipitating severe withdrawal if administered too early. The gradual transition through oral buprenorphine allows for safer adjustment before committing to the long-acting injectable form, which provides steady blood levels for a month and helps prevent relapse by eliminating the need for daily dosing decisions, as noted in the study 1.
From the Research
Transitioning from Fentanyl to Sublocade (Buprenorphine)
To transition from fentanyl to Sublocade (buprenorphine), it is essential to consider the risk of precipitated withdrawal. The following points outline the best approach:
- Wait for adequate opioid withdrawal: Before initiating buprenorphine, it is crucial to wait until the individual is in mild to moderate opioid withdrawal, as buprenorphine can precipitate withdrawal if a full mu-opioid receptor agonist is still present in the system 2.
- High-dose buprenorphine-naloxone for precipitated withdrawal: If precipitated withdrawal occurs, high-dose buprenorphine-naloxone (up to 20 mg) can be administered to rapidly reverse withdrawal symptoms 2.
- Timing of buprenorphine induction: The odds of developing severe withdrawal symptoms increase when taking buprenorphine within 24 hours after fentanyl use, and within 24 to 48 hours after fentanyl use 3.
- Comparison with methadone: Methadone does not appear to precipitate withdrawal in the same way as buprenorphine after fentanyl use, suggesting that this effect is specific to buprenorphine 3.
- Extended-release buprenorphine injection: For patients transitioning from sublingual buprenorphine to Sublocade, a single injection of 100 mg extended-release buprenorphine may facilitate discontinuation of sublingual buprenorphine and mitigate prolonged withdrawal symptoms 4.
Key Considerations
- Risk of precipitated withdrawal: Buprenorphine can precipitate withdrawal in individuals with recent fentanyl use, and the prevalence of this phenomenon is not clinically established 3.
- Importance of medical supervision: Transitioning from fentanyl to Sublocade should be done under medical supervision to minimize the risk of precipitated withdrawal and ensure a safe and effective transition.
- Individualized treatment approach: The best approach for transitioning from fentanyl to Sublocade may vary depending on individual factors, such as the severity of opioid use disorder and medical history.