Guidelines for Long-Acting Injectable Buprenorphine in Opioid Use Disorder Treatment

Patient Selection and Preparation

The American College of Physicians recommends long-acting injectable buprenorphine for patients with opioid use disorder who have been stabilized on transmucosal buprenorphine, with initial 300 mg monthly doses followed by maintenance doses of 100 mg monthly, combined with behavioral therapies 1
Patients must demonstrate tolerance to buprenorphine before initiating long-acting injectable formulations to minimize risk of precipitated withdrawal 1
Assessment should include evaluation of the patient's risk of relapse, expected level of opioid withdrawal symptoms, and comorbid conditions 1

Stabilize the patient on 8-24 mg daily of sublingual or buccal buprenorphine for a minimum of 7 consecutive days before transitioning to injectable formulations 1
Ensure the patient is not experiencing withdrawal symptoms and is comfortable on their oral buprenorphine dose 1
After stabilization, transition to Sublocade with the first two monthly doses at 300 mg, followed by maintenance doses of 100 mg monthly 1

Monitor patients closely after the first injection for signs of precipitated withdrawal, especially if the patient was recently using full opioid agonists 1
Be aware that concomitant use of buprenorphine with QT-prolonging agents is contraindicated 1
Multiple drug-drug interactions can result in QT-interval prolongation, serotonin syndrome, paralytic ileus, reduced analgesic effect, or precipitation of withdrawal symptoms 1

For pregnant women with opioid use disorder, medication-assisted therapy with buprenorphine has been associated with improved maternal outcomes 2
For patients with inadequate analgesia on buprenorphine maintenance, consider increasing the dosage in divided doses before transitioning to long-acting formulations 1
Be cautious with patients who may require surgery, as buprenorphine's high binding affinity may interfere with perioperative pain management 1

Physicians not already certified to provide buprenorphine in an office-based setting can undergo training to receive a waiver from the Substance Abuse and Mental Health Services Administration (SAMHSA) 2
Physicians prescribing opioids in communities without sufficient treatment capacity for opioid use disorder should strongly consider obtaining this waiver 2
Clinicians should identify treatment resources for opioid use disorder in the community and work together to ensure sufficient treatment capacity 2

Do not attempt to remove long-acting injectable buprenorphine after administration, as the risks include surgical complications, infection, and damage to surrounding tissue 1
For patients with problematic opioid use that does not meet criteria for opioid use disorder, clinicians can offer to taper and discontinue opioids 2
Consider offering naloxone for overdose prevention to patients with opioid use disorder 2

The Centers for Disease Control and Prevention recommends that all medication-assisted treatments for opioid use disorder, including long-acting buprenorphine formulations, be combined with behavioral therapies 3
Evidence-based treatment for opioid use disorder typically includes medication-assisted treatment with buprenorphine or methadone in combination with behavioral therapies, as suggested by the CDC 3
Integrated treatment approaches that address substance use disorders alongside other health issues show improved outcomes, according to the American Medical Association 4

The American College of Physicians recommends that providers have appropriate training and certification to prescribe buprenorphine products for opioid use disorder 5
Barriers to buprenorphine treatment include lack of institutional support, insufficient resources, and lack of specialty backup, as noted by the American College of Physicians 5