Sublocade: It's History and How It's Used

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The following is a transcription from the above video on Sublocade, it's history and everything you should know about it.

Hi, everybody. Today’s topic is going to be, what is Sublocade and what is it useful, uh, for those of you that are new to this channel? My name is Dr. B with Dr. B addiction recovery. And on this channel, we cover all things, substance abuse and related topics based on science and clinical experience.

What is Sublocade?

sublocade injection

The question today, what is Sublocade as sort of an add on to a recent video that I did, which was the three FDA approved medications for opiate use disorder. I classified that group of medications as the first one being methadone, which is considered a full agonist therapy for long-term assistance with the opiate abuse and going down the line, we went that to buprenorphine products, and that is a, usually a sublingual agonist antagonists also indicated for long term, what’s often known as medication assisted treatment, which is a term no longer used. And finally, another approved medication is the Naltrexone products. People often know it as a Vivitrol depo shot, or nowadays you can even get implants that last one to two months, that medication is an antagonist. And I had a discussion about this is not truly long-term therapy, but it’s relapse prevention going along that same line. We’re going to go back to the agonist antagonist group, which is that people, Norfolk products, uh, often, uh, presented nowadays as a sublingual medication, uh, and, uh, 2017, April of 2017, the FDA approved Sublocade injection for one month. And it is exactly the same thing as buprenorphine often known as Suboxone.

So, some differences I want to make here and people often ask, well, should I get on Sublocade? Uh, is it better than Suboxone, buprenorphine Subutex? I want to make some distinctions here with these, uh, this group of medications within the agonist antagonist group. Uh, so as most of you know, you know, the term Suboxone, and you also have heard the term Subutex, and there is a few other brands and formulations that active ingredient in all of these medications is buprenorphine. And that is the agonist antagonist that actually blocks that, or binds that in opiate meal receptors and you get the clinical effect, these medications are sublingual or dose one, two, three, four times daily, the same company that produces Suboxone, which also has an all trucks and the locks on component in it, which is actually neither here or there or not important for this discussion, because it doesn’t do anything, uh, in your body, uh, when you take it sublingually, uh, that same company makes Sublocade and this medication is what’s considered a depo injection subcutaneous, right?

And it’s a once a month injection. So how is this done? And what is the, what are the indications and how are you supposed to do it? First of all, as the company, uh, labels it and what the studies they, uh, did, uh, the expectation is you are at least on seven days of sublingual subutex Suboxone, or buprenorphine before you make that transition over to the depo injection of Sublocade, Subutex, buprenorphine, whatever you want to call it. They want you to use that form. So you can get a dose adjustment, 16 milligrams, 24 milligrams, 12 milligrams, before you move to the Sublocade. Uh, and this makes sense. And, uh, one of the concerns I have here, and one of the things that I see happening here is the fact that, uh, many programs or many folks are thinking they can just jump into this medication immediately.

And you can’t because at the root of it, substance abuse or addiction to opiates, uh, is much more than just taking some medication as important as that is. So, number one, you have to be on, sublingual products for at least seven days to stabilize. And I, for the most part, agree with that after this is done, and let’s assume you’ve achieved some stabilization, uh, you are going to get this medication. And basically it’s an injection. It’s a, quite a thick fluid, and there is a technology that delivers it. And the technology is called ACRA gel. That’s the delivery, uh, system, the technology of the delivery system. Uh, it’s a deposit okay. Of a solution. And over the month, this solution releases, uh, increments of the total dose of your buprenorphine, the way they have, the way you can think of it as that, uh, it’s deposited in your subcutaneous fat tissues.

And every day, a certain amount of milligrams is released over a month. So you don’t have to take the sublingual medication. Uh, the first two months, the way the company, uh, lays it out is that you want to go with the 300 dose. And once you get a certain amount in your bloodstream and system, you can go down to the 100 milligram dose. That is how they kind of sell it. And that’s how it’s been written up. And that’s what the studies have shown that you should be doing. And I’ll add some thoughts about that. And, uh, at that point, uh, and in addition to that, uh, dosing equivalent recommendations for the sublingual, Suboxone is 16 to 24 milligrams. If you’re going to do 300 month, one, 300 month, two, and then 100 milligrams month three. Now, if you do the addition or need divide up the 300 by 30, it doesn’t seem like it adds up to 16 to 24 milligrams.

And that’s because of the fact that what, once it’s in your body, in a way you take it, that delivery and the amount of Suboxone that’s actually active changes. So you sort of need a little bit less, and that’s important to understand. Uh, finally, what I really want to get into is, uh, uh, does this medication work and, uh, uh, some of the nuances that I’ve experienced was that, uh, what are some of the positives? What are some of the benefits? Well, some of the obvious, uh, uh, uh, positives about this medication is that, uh, the patient doesn’t have to be dosing all day, every day sublingually. And usually this, uh, buprenorphine products tastes horrible. Uh, this is a positive for some people and a negative for some people, uh, we know the obvious positives, but the negative says that I’ve had some patients that, uh, find a ritual of dosing.

Sublingually an important part of the recovery, and that’s okay with me. And, uh, these are very compliant patients that want to stay under buprenorphine, oral product, and they continue to do so. Uh, some of the positives on the side of having the shot, uh, what does it do? Uh, it takes away the time, the effort, uh, some of the social characteristics particular to that individual patient. For example, he might be working at a law firm or around family, and he doesn’t want to take this medication. Uh, and those ways, this is a very big positive to have that once a month depo injection at the same time, from a practitioner perspective, sometimes I use it, uh, to increase compliance with the medication. And this works for, uh, quite a few people. Now, it certainly isn’t gonna work when a patient is adamant about using, uh, because in that case, they’re not going to get this medication, but it does work with the quite a few of my patients that, uh, and most of them are this way, my practice, where I have a really strong rapport with, and they’re very open about their use or skipping their doses and wanting to use they themselves want that added security of having the injection, that sort of begs the question, uh, of, uh, kinder be use on top of the injection.

Or can you add Suboxone on top of the injection? And the third question is, can you stay on the 300 milligrams if needed itself? And I’m going to answer all three of those, uh, in a couple of dozen cases where I’ve introduced Sublocade into, uh, the practice or the patient’s plan of care. I’ve had one case where the patient, um, continued to use high doses of fentanyl on top of this medication. Um, and that was kind of odd, but again, it’s important to know all the outliers and the surrounding courage juristics of each one of these things, especially when they’re relatively new, it’s three years since it’s been introduced. So I have, I have had one patient that would get this medication and use high doses of fentanyl, and that patient’s case, there were also using high doses of benzos or were using high doses of Gabapentin, and they were using high doses of methamphetamines.

And we continued this for a couple of months. And another thing that I have noticed with some patients is that, uh, I have to get this medication on board within exactly 25 days as those last few days of the end of the month, start to approach for some reason, their cravings seem to increase and they’re more likely to use. So I mitigate that by tailoring the dosing around that time. And this seems to work for most of those patients, which is a small subset, the patients that I have. Uh, finally, the other thing is, uh, some patients, once you go to the 100 milligrams or a few very few where you stay at the 300 milligrams, they very honestly will tell you, uh, they still need a little more, uh, Suboxone or buprenorphine products. And then those cases, I go ahead and prescribe maybe 10 strips of eight milligrams or 10 pills of eight milligrams.

So they get their Sublocade injection and they might be taking four to eight milligrams a day on top of that. The other way I mitigate that is some patients, again, very few. I just simply stay on the 300 milligram dose, uh, indefinitely, uh, until I want to get them off of it. Uh, so, uh, all of these things are certainly outside the written indications, but they can be, and they will become off-label uses that are probably going to be accepted within the standards of care and practice for this type of medication and treatment of opiate use disorder. One other issue I want to discuss is, is there any additional complications with using Sublocade versus using that oral form or the sublingual form and, uh, besides the usual, uh, issues of endocrinopathies, you know, low testosterone and, uh, constipation? Um, well, we are, are actually introducing a large needle in your skin, and that comes with its issues of, uh, infections, uh, localized reactions, that pain at the injection site and so forth.

Finally, one other thing that I think a lot of people may not know about is in the first few days after day injection and the event that a depo needs to be taken out, you can actually go into the site and remove the product. Uh, it seems unbelievable because it’s in liquid form, but you have to remember it’s a deposit and it actually, uh, to some extent solidifies, uh, and within the first, I believe a week, you can remove this product. Otherwise, the way it works is it’s a biodegradable product over the month and it degrades away and slowly releases the buprenorphine. Uh, I am starting to use this more and more in my practice. Again, what I see in general is patient comfort and desire. Uh, they don’t like the taste of the oral medication. They have a busy lifestyle. Uh, they have issues where they want to keep it private, to the extent that they’re putting people North in products under their tongue.

And a third group of patients is, uh, the ones that there are some compliance issues with, but not all the patients that there’s compliance issues with because the ones that are so extreme and radical, uh, they will either not get the depo injection of Sublocade or they will use on top of it. Again, I’ve had very, very, very few of those as I described. And the complications, additional complications are the fact that you’re introducing a foreign body into the skin. Uh, I suspect over time, uh, this will become more and more sort of the go-to medication in terms of the fact that people are also on highly sensitive jobs at this time. Something like vivitrol now trucks on injections are considered a safety mechanism. Let’s say, if you are a conductor on a train or a pilot or an engineer, any job that has a lot of safety issues, and Vivitrol has thought of that, that safety medication. Well, uh, in many ways, if the time is appropriate, where you need to be on this sort of therapy medication assisted treatment, long-term this adds extra security for the employer of that patient. And they’re remaining sober and cognitively alert for work. Uh, if you liked the content in this video, I want to know some more, go ahead and click above to my left. If you enjoyed it and like the channel, please subscribe below to my left and hit the like button. I’ll see you guys soon. Thank you.

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