Would it be safer for a patient with polysubstance abuse, currently on Suboxone (buprenorphine) and seen weekly due to ongoing cocaine use, to be switched to Sublocade (buprenorphine) from a harm reduction perspective?

Sublocade is Safer than Suboxone for Patients with Polysubstance Abuse and Ongoing Cocaine Use

For a patient with polysubstance abuse who is currently on Suboxone and seen weekly due to ongoing cocaine use, switching to Sublocade (extended-release buprenorphine) would be safer from a harm reduction perspective.

Rationale for Switching to Sublocade

Advantages of Sublocade for Polysubstance Users

• Improved Medication Adherence: Monthly injections eliminate daily dosing, which is particularly beneficial for patients with chaotic lifestyles or unstable housing common in polysubstance use 1
• Reduced Diversion Risk: Injectable form prevents medication diversion, selling, or sharing - a significant concern with sublingual Suboxone 2
• Stable Blood Levels: Provides consistent buprenorphine blood levels without daily peaks and troughs, which may help reduce cravings and potential for supplemental drug use 2
• Reduced Overdose Risk: The combination of benzodiazepines (often used with cocaine) and opioids increases overdose risk nearly four-fold; Sublocade's controlled-release mechanism may mitigate this risk 1

Evidence for Buprenorphine in Cocaine Users

• Buprenorphine has shown potential efficacy for reducing cocaine use in patients with opioid use disorder 3, 4
• A study demonstrated that opioid-dependent cocaine users had similar buprenorphine treatment outcomes compared to non-cocaine users, with no significant difference in 6-month treatment retention or self-reported opioid use 5
• This contradicts older treatment guidelines suggesting polysubstance users may not be appropriate candidates for office-based buprenorphine treatment 5

Implementation Considerations

Transition Process

1. Baseline Assessment: Ensure patient is currently stable on at least 8mg daily of sublingual buprenorphine before transition
2. Initial Dosing: Standard Sublocade initiation involves 300mg monthly for the first two months, followed by maintenance doses of 100mg or 300mg monthly based on clinical response
3. Monitoring: Continue weekly visits initially to monitor response, then potentially decrease frequency if stability improves

Monitoring for Polysubstance Use

• Continue regular urine drug testing for both opioids and cocaine
• Implement more intensive counseling focused on cocaine use reduction
• Consider additional psychosocial supports specific to polysubstance use

Potential Pitfalls and Considerations

Important Cautions

• Injection Site Reactions: Monitor for and manage potential injection site reactions
• Precipitated Withdrawal: Ensure patient is already stable on sublingual buprenorphine before transitioning to avoid precipitated withdrawal
• Insurance Coverage: Verify insurance coverage as Sublocade is significantly more expensive than sublingual buprenorphine
• Concurrent Benzodiazepine Use: If the patient is also using benzodiazepines (common with cocaine), this increases overdose risk and requires careful monitoring 1, 6

Special Considerations

• If the patient has severe hepatic impairment, dose adjustments may be necessary 1
• Assess for co-occurring mental health conditions that may be driving cocaine use 1

From a harm reduction perspective, Sublocade offers significant advantages over Suboxone for patients with ongoing cocaine use by providing consistent medication levels, eliminating daily dosing requirements, preventing diversion, and potentially reducing the risk of overdose from polysubstance use.