Transitioning from Kratom to Sublocade (Extended-Release Buprenorphine)
Initiate sublingual buprenorphine-naloxone first using home induction protocols, stabilize the patient on an appropriate maintenance dose (typically 12-16 mg daily based on kratom consumption), then transition to monthly Sublocade injections once stable.
Step 1: Assess Kratom Use and Determine Initial Buprenorphine Dose
The starting dose of buprenorphine-naloxone correlates strongly with daily kratom consumption 1:
- Kratom <20 g/day: Start with 4-8 mg buprenorphine-naloxone daily 1
- Kratom 20-40 g/day: Start with 8-12 mg buprenorphine-naloxone daily 1
- Kratom >40 g/day: Start with 12-16 mg buprenorphine-naloxone daily 1
The correlation coefficient between kratom dose and required buprenorphine dose is 0.84, indicating a strong linear relationship 1.
Step 2: Initiate Buprenorphine-Naloxone (Home Induction)
Critical timing consideration: Unlike traditional opioid induction, kratom users may not require the same withdrawal waiting period, though mild withdrawal symptoms should ideally be present 2, 3.
Home Induction Protocol:
- Initial assessment via telehealth is feasible and has been successfully implemented 2, 3
- Patients can safely perform unobserved home induction with appropriate counseling 2, 3
- Start with the calculated dose based on kratom consumption 1
- Monitor for precipitated withdrawal (though risk appears lower than with traditional opioids) 2
Key advantage: Kratom users have successfully undergone home induction without adverse effects, making this approach practical for outpatient settings 2, 3.
Step 3: Stabilization Phase on Sublingual Buprenorphine
- Target maintenance dose: Most patients stabilize on 12-16 mg daily, though individual variation exists 4, 1
- Duration factors: Beyond daily kratom dose, duration of use and psychological factors influence optimal dosing 2
- Patients should demonstrate stability for at least several weeks before transitioning to Sublocade 4
- Monitor for kratom abstinence, improved mood, and sleep patterns 3
Step 4: Transition to Sublocade
Once stabilized on sublingual buprenorphine-naloxone:
Dosing Conversion:
- Patients on 8-24 mg sublingual buprenorphine: Start with Sublocade 300 mg monthly for 2 months 5
- Maintenance: Continue with 100 mg monthly thereafter 5, 4
Administration Considerations:
- Sublocade provides steady-state buprenorphine levels without daily dosing 4
- The extended-release formulation eliminates concerns about daily adherence 4
- Can be used for maintenance or as part of a taper strategy 4
Special Considerations and Pitfalls
Avoid These Common Errors:
Do not wait for severe withdrawal: Unlike methadone or long-acting opioids requiring 36-48 hours of abstinence 5, kratom users may tolerate earlier induction 2, 3.
Do not underdose: Patients using high kratom doses (>40 g/day) require adequate buprenorphine (12-16 mg) to prevent relapse 1.
Do not rush to Sublocade: Ensure stability on sublingual formulation first, as individual dose requirements vary significantly despite similar kratom use patterns 2.
Monitoring Parameters:
- Withdrawal symptoms: Use Clinical Opiate Withdrawal Scale if needed 5
- Kratom abstinence: Verify through patient report and clinical assessment 3
- Functional improvement: Assess mood, sleep, and ability to resume normal activities 3
- Comorbid conditions: Address concurrent psychiatric conditions (ADHD, depression) that may have contributed to kratom use 3
Alternative Approach: Microdosing Protocol
If the patient is already on methadone or another full opioid agonist, a microdosing protocol can transition them to buprenorphine without requiring opioid abstinence 6. However, this is typically not necessary for kratom users, who can usually undergo standard induction 2, 3, 1.
Tapering Considerations (If Applicable)
If eventual discontinuation is the goal, extended-release buprenorphine facilitates tapering 4: