When should Sublocade (buprenorphine) 100 mg be initiated in patients with opioid use disorder?

When to Start Sublocade 100 mg for Opioid Use Disorder

Sublocade 100 mg should be initiated after patients have achieved clinical stability on a transmucosal buprenorphine-containing product, delivering at least 8-24 mg per day for a minimum of 7 days. 1

Patient Selection and Preparation

• Sublocade (buprenorphine extended-release) 100 mg is indicated for patients with opioid use disorder (OUD) who have already been stabilized on a transmucosal (sublingual or buccal) buprenorphine product 1
• The patient must demonstrate tolerance to buprenorphine before initiating Sublocade to minimize risk of precipitated withdrawal 1
• Patients should be assessed for their risk of relapse, expected level of opioid withdrawal symptoms, and comorbid conditions before determining the appropriate timing for Sublocade initiation 1

Specific Initiation Protocol

• First, stabilize the patient on 8-24 mg daily of sublingual or buccal buprenorphine for a minimum of 7 consecutive days 1
• Ensure the patient is not experiencing withdrawal symptoms and is comfortable on their oral buprenorphine dose 1
• After stabilization, transition to Sublocade 100 mg monthly subcutaneous injection 1
• The first two monthly doses should be 300 mg, followed by maintenance doses of 100 mg monthly (though this can be increased to 300 mg monthly based on patient response) 2

Clinical Considerations

• Individualize the decision to initiate Sublocade based on the patient's daily buprenorphine dose, indication for treatment (pain vs. dependency), and risk of relapse 1
• Be aware that concomitant use of buprenorphine with QT-prolonging agents is contraindicated 1
• Multiple drug-drug interactions can result in QT-interval prolongation, serotonin syndrome, paralytic ileus, reduced analgesic effect, or precipitation of withdrawal symptoms 1

Special Situations

• For patients with inadequate analgesia on buprenorphine maintenance, consider increasing the dosage in divided doses before transitioning to Sublocade 1
• For patients with chronic pain who are transitioning from full opioid agonists, ensure they are in mild withdrawal before initiating any form of buprenorphine to avoid precipitated withdrawal 1
• For patients who cannot tolerate withdrawal symptoms during traditional induction, consider low-dose initiation (microdosing) of oral buprenorphine before transitioning to Sublocade 3

Monitoring After Initiation

• Monitor patients closely after the first injection of Sublocade for signs of precipitated withdrawal, especially if the patient was recently using full opioid agonists 1
• Assess for adequate control of opioid cravings and withdrawal symptoms 4
• Higher doses of buprenorphine (up to 32 mg/day) have been associated with improved outcomes including decreased opioid use, reduced frequency of use, and better retention in treatment 4

Potential Pitfalls

• Avoid abrupt discontinuation of Sublocade as it may lead to withdrawal symptoms that can persist for weeks or months due to the long-acting nature of the formulation 5
• Be cautious with patients who may require surgery, as Sublocade's high binding affinity may interfere with perioperative pain management 1
• Do not attempt to remove Sublocade after administration, as the risks include surgical complications, infection, and damage to surrounding tissue 2