What is the recommended approach for transitioning a patient with a history of opioid use disorder, possibly other substance use disorders, and Kratom use, who is currently stable on Suboxone (buprenorphine and naloxone), to Sublocade (buprenorphine)?

Transitioning from Suboxone to Sublocade in a Stable Patient

For a patient stable on Suboxone with a history of opioid use disorder and Kratom use, transition to Sublocade by ensuring at least 7 consecutive days of stable sublingual dosing at 8 mg daily, then administer 300 mg subcutaneous Sublocade monthly for the first two doses, followed by 100 mg monthly maintenance. 1

Pre-Transition Stabilization Requirements

Confirm the patient has been stable on their current Suboxone 8 mg daily dose for a minimum of 7 consecutive days before initiating Sublocade. 1 This stabilization period is critical to ensure the patient is not experiencing withdrawal symptoms and has developed adequate tolerance to buprenorphine. 1

Essential Pre-Transition Assessment

• Verify the patient is not experiencing any withdrawal symptoms on their current dose to minimize risk of precipitated withdrawal after Sublocade administration. 1
• Screen all current medications for QT-prolonging agents, as concomitant use with buprenorphine is contraindicated due to cardiac complication risk. 1, 2
• Evaluate comorbid conditions, particularly given this patient's history of polysubstance use including Kratom, which may complicate treatment. 1
• Assess relapse risk factors, as patients with polysubstance use disorders (including Kratom) may require closer monitoring. 3

Sublocade Dosing Protocol

Administer 300 mg subcutaneous Sublocade injections monthly for the first two doses. 1 This initial higher dosing is FDA-recommended regardless of the patient's current oral dose. 1

After the first two 300 mg doses, transition to 100 mg monthly maintenance injections. 1 The 100 mg maintenance dose is specifically appropriate for patients previously stabilized on 8-24 mg daily of transmucosal buprenorphine, which includes this patient on 8 mg daily. 1

Timing Considerations

Recent evidence suggests that rapid transition to extended-release buprenorphine within 7 days or even 24 hours of the last sublingual dose is feasible and well-tolerated, with short-term retention exceeding 60% and minimal withdrawal symptoms. 4 However, the FDA-approved protocol recommends the 7-day stabilization period for optimal safety. 1

Critical Warnings and Pitfalls

Counsel the patient that Sublocade cannot be removed after administration. 1 Removal attempts carry significant risks including surgical complications, infection, and tissue damage. 1 This is particularly important for patients with complex substance use histories who may have ambivalence about long-acting formulations.

Exercise caution if the patient requires surgery while on Sublocade, as its high binding affinity may interfere with perioperative pain management. 1 This is especially relevant given that buprenorphine's high receptor affinity can block effects of other opioids. 5

Avoid inadequate stabilization on the current sublingual dose, as brief treatment periods with rapid tapers are associated with high relapse rates. 1 This is particularly concerning in patients with polysubstance use including Kratom, who may require higher levels of care. 3

Special Considerations for Kratom Use History

Patients with Kratom dependence can be effectively treated with buprenorphine/naloxone, and maintenance dosing for Kratom use is similar to that used in opioid use disorder. 3 However, polysubstance use with Kratom dependence may require higher doses of buprenorphine (up to 24 mg daily in some cases) and higher levels of care. 3

Prolonged withdrawal symptoms may persist despite buprenorphine treatment in patients with Kratom use history. 3 If this occurs after Sublocade transition, additional supportive measures may be needed, though the long-acting formulation should provide steady-state coverage.

Ongoing Monitoring After Transition

Continue regular urine drug testing to assess for illicit opioid use and Kratom use. 5, 2 Facilities treating patients with Kratom history should have testing available for Kratom alkaloids. 3

Maintain counseling and behavioral therapies as an essential component of treatment, as medication alone has poor long-term outcomes. 5, 2 This whole-patient approach is particularly important for patients with polysubstance use histories. 5

Reassess using DSM-5 criteria at follow-up visits to monitor treatment response and ensure continued remission. 5, 2