Does literature support stopping Suboxone (buprenorphine/naloxone) after a one-time injection of Brixadi (buprenorphine) or Sublocade (buprenorphine) to wean off buprenorphine?

Using Extended-Release Buprenorphine (Brixadi/Sublocade) for Weaning Off Suboxone

Current literature does support using a one-time injection of extended-release buprenorphine (Brixadi or Sublocade) to facilitate discontinuation of Suboxone (buprenorphine/naloxone), as this approach provides a gradual taper with minimal withdrawal symptoms.

Evidence Supporting This Approach

Extended-release buprenorphine formulations offer several advantages for discontinuing buprenorphine therapy:

• A 2023 case series demonstrated that patients interested in voluntarily discontinuing sublingual buprenorphine were successfully transitioned to extended-release buprenorphine, allowing them to discontinue treatment with minimal withdrawal symptoms 1

• The long terminal half-life of extended-release buprenorphine provides a natural, gradual taper effect that helps minimize withdrawal symptoms compared to abrupt discontinuation of sublingual formulations 1

• This approach maintains therapeutic buprenorphine levels while avoiding the daily decision-making process associated with taking sublingual medications

Implementation Considerations

When implementing this approach, consider the following:

1. Patient Selection

   • Best candidates are those who:
     • Have demonstrated stable recovery
     • Have strong psychosocial support systems
     • Are not experiencing active co-occurring mental health issues
     • Have a clear understanding of the increased risk of relapse after discontinuation

2. Preparation

   • Ensure the patient is on a stable dose of Suboxone before transition
   • Discuss the increased risk of overdose following discontinuation due to reduced tolerance
   • Provide naloxone and overdose prevention education

3. Transition Process

   • Administer the extended-release injection (Brixadi or Sublocade)
   • Discontinue daily Suboxone after the injection is administered
   • The extended-release formulation will provide a gradual, physiologic taper over 1-2 months

Monitoring and Follow-Up

• Schedule regular follow-up appointments to monitor for withdrawal symptoms
• Use the Clinical Opiate Withdrawal Scale (COWS) to objectively assess withdrawal
• Continue counseling and support services throughout the process
• Monitor for signs of relapse or cravings

Risks and Considerations

• There is a risk of relapse to opioid use after discontinuation of buprenorphine therapy
• The risk of overdose is significantly increased after discontinuation due to reduced tolerance
• Extended-release formulations cannot be removed once administered, so patient commitment is essential
• Limited research exists on this specific approach, though preliminary evidence is promising 1

Alternative Approaches

If the one-time injection approach is not suitable:

• Traditional tapering of sublingual buprenorphine over several weeks/months
• Transition to a lower dose of sublingual buprenorphine before attempting discontinuation
• Continued maintenance therapy if risks of discontinuation outweigh benefits

Conclusion

While the literature supporting this specific approach is still emerging, the 2023 case series provides promising evidence that a one-time injection of extended-release buprenorphine can facilitate the discontinuation of Suboxone with minimal withdrawal symptoms 1. This approach leverages the pharmacokinetic properties of extended-release formulations to provide a gradual, physiologic taper that may be more comfortable and successful than traditional tapering methods.