What is the recommended approach for switching a patient with a history of opioid use disorder, currently stable on Suboxone (buprenorphine/naloxone) 8mg, to Sublocade (buprenorphine)?

Switching from Suboxone 8 mg to Sublocade

For a patient stable on Suboxone 8 mg daily, continue the current sublingual dose for a minimum of 7 consecutive days to ensure stabilization, then initiate Sublocade with two monthly 300 mg subcutaneous injections followed by 100 mg monthly maintenance doses. 1

Pre-Transition Requirements

Stabilization Period:

• The patient must remain on their current sublingual buprenorphine/naloxone 8 mg daily dose for at least 7 consecutive days before transitioning to Sublocade 1
• Confirm the patient is not experiencing withdrawal symptoms and is comfortable on their current oral dose 1
• Assess for tolerance to buprenorphine to minimize risk of precipitated withdrawal 1

Patient Assessment:

• Evaluate risk of relapse, expected level of opioid withdrawal symptoms, and comorbid conditions before determining timing 1
• Screen for QT-prolonging medications, as concomitant use with buprenorphine is contraindicated 1
• Review all medications for potential drug-drug interactions that could cause QT-interval prolongation, serotonin syndrome, paralytic ileus, or reduced analgesic effect 1

Sublocade Dosing Protocol

Initial Dosing:

• Administer Sublocade 300 mg subcutaneous injection monthly for the first two doses 1
• This higher initial dose is required regardless of the patient being on only 8 mg sublingual buprenorphine 1

Maintenance Dosing:

• After the two 300 mg doses, transition to Sublocade 100 mg monthly subcutaneous injections 1
• The 100 mg maintenance dose is appropriate for patients previously stabilized on 8-24 mg daily of transmucosal buprenorphine 1

Injection Site Options:

• Standard site is the abdomen 2
• Alternative sites include upper arm, thigh, or buttocks, which show comparable bioavailability and safety 2
• Rotating injection sites may improve patient comfort given the chronic nature of treatment 2

Timing of Transition

Same-Day Transition:

• Recent evidence suggests transitioning to extended-release buprenorphine within 24 hours of the last sublingual dose is feasible and well-tolerated 3
• In studies of 75 patients transitioning within 24 hours, only 4% experienced withdrawal symptoms requiring additional opioid support 3
• Short-term retention at 4 weeks exceeded 60% with this approach 3

Traditional Approach:

• The FDA-approved protocol requires 7 days of stabilization on sublingual buprenorphine before Sublocade initiation 1
• This remains the standard recommendation, though emerging data supports more rapid transitions 3

Post-Injection Monitoring

Immediate Monitoring:

• Monitor closely after the first Sublocade injection for signs of precipitated withdrawal, particularly if the patient has recently used full opioid agonists 1
• Assess injection site for pain, tenderness, erythema, induration, and swelling 2

Common Adverse Events:

• Injection site pain, nausea, and constipation are the most frequently reported adverse events 3
• These are typically mild and self-limited 3

Critical Pitfalls to Avoid

Surgical Considerations:

• Be cautious with patients who may require surgery, as Sublocade's high binding affinity may interfere with perioperative pain management 1
• Plan ahead for any anticipated surgical procedures before initiating Sublocade 1

Irreversibility:

• Do not attempt to remove Sublocade after administration, as removal risks include surgical complications, infection, and tissue damage 1
• This is a critical counseling point before initiating therapy 1

Inadequate Stabilization:

• Do not rush the transition if the patient is not truly stable on their current sublingual dose 1
• Longer-term maintenance treatment is generally indicated for opioid dependence, as brief treatment periods with rapid tapers are associated with high relapse rates 4

Advantages of Sublocade Over Sublingual Formulations

• Monthly dosing eliminates daily medication adherence challenges 3
• Reduced diversion potential compared to sublingual formulations 5
• Sustained therapeutic buprenorphine plasma concentrations at approximately 2 ng/mL or above throughout the dosing interval 2
• May improve treatment retention in high-risk populations 3