Concurrent Use of Sublocade and Suboxone
No, you should not use Sublocade (extended-release buprenorphine injection) and Suboxone (sublingual buprenorphine/naloxone) at the same time for routine maintenance therapy. These are both buprenorphine formulations designed to occupy the same mu-opioid receptors, and using them together provides no additional therapeutic benefit while increasing the risk of excessive sedation and respiratory depression. 1
Understanding the Two Formulations
Sublocade is a monthly subcutaneous depot injection that releases buprenorphine continuously over 28-30 days, maintaining steady therapeutic blood levels throughout the month. 1
Suboxone is a sublingual tablet or film containing buprenorphine plus naloxone, designed for daily dosing with peak effects occurring 1-3 hours after administration. 1, 2
Both medications work by occupying approximately 95% of mu-opioid receptors at therapeutic doses (16 mg daily equivalent), creating a ceiling effect that prevents withdrawal while blocking the euphoric effects of other opioids. 3
The Only Exception: Transition Period
The sole clinical scenario where both medications may overlap is during the initial transition from Suboxone to Sublocade. 1
Transition Protocol:
Week 1-2: Continue daily Suboxone at your established maintenance dose (typically 16 mg daily) while the first Sublocade injection begins releasing buprenorphine. 3, 4
Week 3-4: Taper Suboxone gradually as Sublocade reaches therapeutic blood levels, reducing the daily dose by 25-50% each week. 3
After Week 4: Discontinue Suboxone entirely once Sublocade provides full coverage. 3
This brief overlap prevents withdrawal symptoms during the transition, as Sublocade takes 7-14 days to reach steady-state blood levels. 1
Why Concurrent Long-Term Use Is Not Recommended
Pharmacologic redundancy: Both medications are buprenorphine formulations that bind to the same receptors with the same mechanism of action—adding Suboxone to established Sublocade therapy cannot increase receptor occupancy beyond the existing 95% ceiling. 3
Increased respiratory depression risk: Combining two buprenorphine sources raises total opioid exposure, particularly dangerous if the patient also takes benzodiazepines or other central nervous system depressants (FDA black-box warning for fatal respiratory depression). 3
No evidence of benefit: Clinical trials demonstrate that Sublocade monotherapy at 300 mg monthly provides equivalent efficacy to daily Suboxone 16-24 mg for preventing relapse and suppressing illicit opioid use. 2
Common Clinical Pitfalls
Patients requesting "breakthrough" Suboxone while on Sublocade: This typically indicates inadequate Sublocade dosing (may need 300 mg monthly instead of 100 mg) or emerging withdrawal from concurrent benzodiazepine or alcohol use—not true opioid withdrawal. 3
Prescribers adding Suboxone for "coverage gaps": Sublocade maintains therapeutic buprenorphine levels for 28-30 days; perceived gaps usually reflect patient anxiety about monthly dosing rather than actual pharmacologic insufficiency. 1
Misunderstanding the naloxone component: The naloxone in Suboxone is poorly absorbed sublingually and serves only to deter injection misuse—it does not enhance therapeutic efficacy or provide additional receptor blockade when combined with Sublocade. 2, 5, 6
What To Do If Withdrawal Symptoms Emerge on Sublocade
First, confirm true opioid withdrawal using the Clinical Opiate Withdrawal Scale (COWS score >8 indicates moderate withdrawal requiring intervention). 3, 4
If COWS >8 on Sublocade monotherapy:
- Increase the Sublocade dose to 300 mg monthly (if currently on 100 mg). 3
- Rule out concurrent withdrawal from alcohol, benzodiazepines, or other substances. 3
- Provide adjunctive symptomatic management: clonidine 0.1-0.2 mg every 6-8 hours for autonomic symptoms, antiemetics for nausea, benzodiazepines for anxiety (with extreme caution due to respiratory depression risk), and loperamide for diarrhea. 3, 7
Do not routinely add daily Suboxone to compensate for inadequate Sublocade dosing—this creates medication redundancy and complicates long-term management. 3
Safety Monitoring for Any Buprenorphine Regimen
Screen for QT-prolonging medications before initiating or combining buprenorphine formulations, as concomitant use is contraindicated due to cardiac arrhythmia risk. 1, 4
Avoid concurrent benzodiazepines whenever possible—the combination carries an FDA black-box warning for respiratory depression and death, with risk dramatically increased at lorazepam doses ≥6 mg daily or equivalent. 3
Provide take-home naloxone kits and overdose prevention education at every visit, as patients on any buprenorphine formulation face elevated overdose risk if they relapse to illicit fentanyl or heroin. 3, 4, 7
Offer hepatitis C and HIV screening as part of comprehensive addiction care. 3, 4