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Getting off Suboxone with Sublocade.

I have been treating patients with Sublocade from close to the time that it came to market. I was excited to be an early adopter of this medication because I could see the potential benefit for my patients. It seemed that an option that didn't require taking something every day would be helpful in reducing the mental stress of being on Suboxone (buprenorphine/naloxone) for opioid use disorder.

One constant annoyance or concern for patients taking buprenorphine is worrying that their medication will run out or worrying that that the pharmacy won't have it or that they will lose it. Many of them have experienced withdrawal and never want to have that experience again. Having a limited supply of medication induces anxiety for some.

From a doctor's point of view, I know that a big part of addiction is the obsession with the substance that the patient is addicted to.  People with addictions often spend much mental energy and time thinking when the next time will be that they will be able to take the drug they are addicted to. This obsession helps to reinforce addiction. I have noticed that sometimes there is a bit of this obsession with taking Suboxone (or other buprenorphine products) in the patients I see. They are often "looking forward" to their next dose, the same way they did with the drugs they are taking the Suboxone to get away from. Of course, they don't feel a "high" or euphoric effect from the Suboxone, but they do look forward to it and sometimes take it as a response to stress or difficult emotions as a way of coping.

When I heard about a monthly way to administer this medication, I realized that it might help people get past this obsession and maybe even forget that they are taking anything. I hypothesized that this would be helpful in healing addiction. This turned out to be true, but I also discovered that there are many more benefits to a monthly injection of buprenorphine instead of daily administration by mouth.

First, the steady concentration of buprenorphine in the blood stream provided by a monthly injection helps to block cravings and allows people to adjust, so they always feel normal. It also prevents relapse by providing constant medication in the bloodstream. Were someone to relapse, they would be very unlikely to get any type of euphoric feeling because the buprenorphine will block the effects of other opioids (please note that trying to overwhelm buprenorphine with increased doses of opioids is incredibly dangerous). Studies show that people who use opioids while on Sublocade do not "like" the effects of the opioids and are less likely to repeat this behavior. 

The thing I didn't anticipate about Sublocade and was pleasantly surprised to find out is that it seems to be a good tool for helping people transition off of Suboxone. I had some experiences early in my work with Sublocade where patients, for distinct reasons couldn't or didn't continue their care with me, then came back after a period away. I noticed an interesting pattern. I noticed that none of them had any withdrawal symptoms for months after stopping Sublocade. 

I had a challenging time tapering many patients off Suboxone who wanted to get off it in the past. People would experience withdrawal that was very disruptive to their lives and often prevented them from getting off the medication, even though they wanted to and were ready to do so. 

It is extremely important to note that the decision to get off medications for opioid use disorder is a profoundly serious one. If one decides to get off this medication prematurely, this could eventually have catastrophic consequences. People are more likely to overdose after a period of sobriety and getting off medication prematurely could increase this risk. The bottom line is that this is a life and death decision, and it should not be taken lightly. People need to have changed their environments, their coping strategies and have new healthy habits before they get off medication. This usually takes years. 

Keeping the above in mind, I started to discuss Sublocade as an option with my patients who wanted to discontinue or get off Suboxone. I always explain that I don't know of research looking at this question and I cannot say from a scientific standpoint whether this is a reliable way to get off Suboxone, but in my limited experience, it seems to work. Almost all of my patients who have had at least 4-5 monthly injections, who then stop Sublocade, experience no withdrawal symptoms. Very few of my patients have experienced mild withdrawal, requiring supplementation with Suboxone or continued use of Sublocade. I have now helped more people get off buprenorphine with Sublocade, than I have Suboxone or any other product. 

Seeing people use Sublocade to get off Suboxone has become one of my favorite parts of my practice because it really feels like I can help people move on and close a difficult chapter in their lives. I never make the decision to start this process, it is always the patient's decision; I do my best to guide them along the way. It is an important, and life-changing decision that could have great benefits, but also could result in severe consequences, so it should be undertaken carefully, slowly and with much preparation and forethought. For those who are ready it can liberate them from dependence on a substance and allow them to have a sense of closure and move on. Facilitating that type of profound change in people's lives keeps me excited about my work and always looking forward to the next person I can help. 

Author
Aaron Rosenberg, MD I am the founder and owner of Rosenberg Medical Clinic. I'm passionate about being a healer, I see this as my life's purpose, and it gives me a sense of meaning. I am constantly curious, and my goal is to never stop learning. I strive to learn something new about medicine every day of my life. Despite continually acquiring knowledge, I am always humble in knowing that that there is more I do not know than what I do know. I find joy in searching to fill the gaps, learning more, while using what I have learned in the service of others. I am blessed to have the opportunity to guide others in their healing process and strive to make the most of it every day.

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