What are the guidelines for using long-acting injectable buprenorphine (opioid partial agonist) for opioid use disorder treatment?

Guidelines for Long-Acting Injectable Buprenorphine in Opioid Use Disorder Treatment

Long-acting injectable buprenorphine is recommended for patients with opioid use disorder who have been stabilized on transmucosal buprenorphine, with initial 300 mg monthly doses followed by maintenance doses of 100 mg monthly, combined with behavioral therapies. 1

Patient Selection and Preparation

• Long-acting injectable buprenorphine (Sublocade) is indicated for patients with opioid use disorder who have already been stabilized on a transmucosal (sublingual or buccal) buprenorphine product delivering 8-24 mg per day for a minimum of 7 days 1
• Patients must demonstrate tolerance to buprenorphine before initiating long-acting injectable formulations to minimize risk of precipitated withdrawal 1
• Assessment should include evaluation of the patient's risk of relapse, expected level of opioid withdrawal symptoms, and comorbid conditions 1
• Long-acting formulations can improve adherence, reduce stigma, and decrease the risk of diversion compared to daily dosing regimens 2

Initiation Protocol

• Stabilize the patient on 8-24 mg daily of sublingual or buccal buprenorphine for a minimum of 7 consecutive days before transitioning to injectable formulations 1
• Ensure the patient is not experiencing withdrawal symptoms and is comfortable on their oral buprenorphine dose 1
• After stabilization, transition to Sublocade with the first two monthly doses at 300 mg, followed by maintenance doses of 100 mg monthly 1
• In certain clinical situations, an accelerated timeline may be considered, though this deviates from product monograph recommendations 3

Clinical Considerations and Monitoring

• Monitor patients closely after the first injection for signs of precipitated withdrawal, especially if the patient was recently using full opioid agonists 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
• Long-acting injectable formulations are available with durations ranging from one week to 6 months, allowing for individualized treatment approaches 2

Special Situations

• For pregnant women with opioid use disorder, medication-assisted therapy with buprenorphine (without naloxone) or methadone has been associated with improved maternal outcomes 4
• For patients with inadequate analgesia on buprenorphine maintenance, consider increasing the dosage in divided doses before transitioning to long-acting formulations 1
• Be cautious with patients who may require surgery, as buprenorphine's high binding affinity may interfere with perioperative pain management 1

Potential Benefits of Long-Acting Formulations

• Improved adherence due to lack of peaks and troughs in blood concentrations 2
• Reduced stigma since patients don't need to attend clinic daily or nearly daily 2
• Facilitation of social and occupational integration and improved quality of life 2
• Decreased risk of diversion and intravenous misuse due to the characteristics of these formulations 2
• Particularly beneficial for specific populations such as individuals being released from prison or those in long-term residential treatment 2

Provider Requirements

• Physicians not already certified to provide buprenorphine in an office-based setting can undergo training to receive a waiver from the Substance Abuse and Mental Health Services Administration (SAMHSA) 4
• Physicians prescribing opioids in communities without sufficient treatment capacity for opioid use disorder should strongly consider obtaining this waiver 4
• Clinicians should identify treatment resources for opioid use disorder in the community and work together to ensure sufficient treatment capacity 4

Important Cautions

• Do not attempt to remove long-acting injectable buprenorphine after administration, as the risks include surgical complications, infection, and damage to surrounding tissue 1
• For patients with problematic opioid use that does not meet criteria for opioid use disorder, clinicians can offer to taper and discontinue opioids 4
• Consider offering naloxone for overdose prevention to patients with opioid use disorder 4