Transitioning from Suboxone to Sublocade: Dosing Protocol
Patients must be stabilized on sublingual buprenorphine (typically 8-24 mg daily, with 16 mg being the most common maintenance dose) for at least 7 days before initiating Sublocade, and should continue their daily Suboxone dose on the same day as the first Sublocade injection and for the first 24 hours to maintain therapeutic levels. 1
Pre-Transition Requirements
- Stabilization period is mandatory: Patients must be on a stable dose of transmucosal buprenorphine before Sublocade initiation 1
- Typical maintenance dose range: 4-24 mg daily, with 16 mg being the standard stabilization dose 1
- Critical safety warning: Never initiate Sublocade in patients not already stabilized on transmucosal buprenorphine, as this will precipitate severe withdrawal 1
Sublocade Dosing Schedule
Initial Dosing
- First two monthly injections: 300 mg subcutaneously 1
- Maintenance dosing: After the first two doses, continue with 300 mg monthly OR reduce to 100 mg monthly based on clinical response 1
Transition Day Protocol
- Continue Suboxone: Administer the patient's regular daily Suboxone dose on the same day as the first Sublocade injection 1
- Overlap period: Continue Suboxone for the first 24 hours following Sublocade injection to maintain therapeutic buprenorphine levels during transition 1
- Discontinuation timing: Stop Suboxone after the first 24 hours post-injection 1
Critical Safety Considerations
Contraindications and Drug Interactions
- Absolute contraindication: Concomitant use with QT-prolonging agents is contraindicated 2, 1
- Multiple drug-drug interactions possible: Risk of QT-interval prolongation, serotonin syndrome, paralytic ileus, or precipitation of withdrawal symptoms 2
- Avoid serotonergic agents: Increased risk of serotonin syndrome when combined with medications that increase serotonergic or noradrenergic activity 2
High-Risk Patient Populations Requiring Closer Monitoring
- Patients with recent history of relapse 1
- Those with concurrent psychiatric disorders 1
- Patients with limited social support 1
- Individuals with cardiovascular disease (due to QT prolongation risk) 2, 1
Expected Side Effects
- Most common: Headache and constipation, which may be more pronounced initially 1
- Injection site reactions: Local reactions at the subcutaneous injection site are common 1
Common Pitfalls to Avoid
Timing Errors
- Do not skip the overlap period: Failing to continue Suboxone for the first 24 hours can result in subtherapeutic buprenorphine levels and withdrawal symptoms 1
- Do not initiate in unstabilized patients: This is the most critical error and will precipitate severe withdrawal 1
Dose Selection Errors
- Do not underdose initially: The first two doses must be 300 mg; starting with 100 mg provides inadequate coverage 1
- Do not assume 1:1 conversion: The depot formulation has different pharmacokinetics than sublingual buprenorphine, requiring the standardized dosing protocol rather than direct conversion 1
Monitoring Failures
- Screen for QT-prolonging medications: Review all concurrent medications before initiating Sublocade 2, 1
- Assess cardiovascular risk: Patients with cardiac history require additional evaluation 2
Clinical Context
The transition from Suboxone to Sublocade represents a shift from daily sublingual dosing to monthly subcutaneous depot injections. The depot formulation provides sustained buprenorphine levels over 28-30 days, eliminating daily dosing requirements and potentially improving adherence 1. However, the partial agonist properties of buprenorphine remain, meaning it continues to have a ceiling effect on respiratory depression while maintaining efficacy for opioid use disorder treatment 3, 4.
The naloxone component in Suboxone serves primarily to deter parenteral abuse and has minimal effect when taken sublingually as prescribed 3, 4. Sublocade contains only buprenorphine without naloxone, as the depot formulation itself provides abuse deterrence through its subcutaneous administration route 1.