Sublocade vs. Suboxone: The Pros and Cons of Two Opioid Treatment Medications

Since its approval in 2002, Suboxone has proven miraculous for countless patients struggling with opioid use disorder (OUD).

Taken daily, as a film that dissolves under the tongue, the medication suppresses withdrawal symptoms and the overpowering, relentless cravings that fuel opioid addiction.

But for some patients, getting to appointments, picking up prescriptions, and taking the medication correctly every day is simply too difficult, leading to relapse.

These are the patients who may be better suited for Sublocade, a similar medication with a key difference: It’s taken as a monthly injection.

“Many patients tell me, ‘Sublocade is the reason I am stable, my recovery isn’t dependent on me taking my meds every day,” says Larry Nye, PA-C, an addiction medicine specialist and Senior Director of Education and Research at Ideal Option.

What’s more, Sublocade provides a higher concentration of buprenorphine, the active ingredient in both medications, than sublingual buprenorphine — a benefit for many patients addicted to fentanyl.

Sublocade isn’t as well-known as Suboxone, as it was only approved by the U.S. Food and Drug Administration (FDA) in 2017. But in the fentanyl era, its advantages are becoming more apparent.

Still, Sublocade has its drawbacks, including prior authorization requirements from insurance providers cost and strict regulations that make the medication difficult to access.

“To get Sublocade in stock involves a lot of labor and red tape for the provider,” says Nye.

If you’re considering treatment for OUD, you may wonder: Which medication is best for you?

Let’s take a closer look at the pros and cons of Sublocade in comparison with Suboxone.

Pro: Sublocade is a monthly injection.

The chief advantage of Sublocade is convenience. Patients visit their provider just once a month, receiving an injection that lasts until their next visit. By contrast, Suboxone patients must pick up their medication at a pharmacy, remember to take it daily, and visit their provider at least once a week, at first, before graduating to every two or three weeks.

“Sublocade is great for people who miss appointments and cycle in and out of treatment,” says Nye.

How Sublocade works

Injected as a liquid, Sublocade transforms into a solid in the body, forming a small lump, called a “depot,” in the abdomen. Over the month, this depot releases enough buprenorphine to suppress withdrawal and cravings in the typical patient addicted to fentanyl.

While many fentanyl patients are successful on Suboxone, they may need to take up to four strips, because fentanyl is so much more addictive than heroin or opioid pills. A single Suboxone strip will usually suffice for patients dependent on opioids other than fentanyl.

Throughout the month, the Sublocade depot releases buprenorphine at a steady rate and gradually shrinks. Patients may experience redness and some discomfort at the injection site, but these side-effects typically are minimal.

“It stings for about 60 seconds, and there’s some pain that can last a couple days but usually goes away. We help minimize the initial pain by placing ice or a topical anesthetic on the area before injection,” says Nye.

Sublocade can cause drowsiness initially, so patients cannot drive or operate machinery immediately following the injection.

For most patients, these are acceptable trade-offs for not needing to find time each day to properly take Suboxone.

How to properly take Suboxone

With Suboxone, following instructions is critical. The medication takes 20 to 30 minutes to melt under your tongue, and during that time (plus immediately before and after), you can’t eat, drink, smoke, talk, or swallow. Otherwise, your body will not absorb enough of the medication.

Patients must find a quiet place and essentially do nothing for a good while, a tall order for some.

“There are lots of distractions that can interfere,” says Nye. “If you talk while taking buprenorphine, you might end up swallowing your medication, in which case your body only absorbs about 10% of it. It is important to not talk or be distracted while taking sublingual buprenorphine. How you take your medication determines the dose you get.”

For fentanyl patients, completing this process twice — once for each strip — proves too cumbersome. The higher daily dose released by Sublocade removes a big obstacle. (Nye does note that, at first, the most addicted fentanyl patients may need to supplement Sublocade with Suboxone.)

Pro: Sublocade is safe with a low risk of diversion.

Another bonus with Sublocade: patients need not worry about keeping their medication away from children or pets or from drug users who may steal it or sell it. Likewise, patients are protected from any temptation of their own to divert the medication for illegal purposes.

To prevent diversion, Suboxone contains a small amount of naloxone (known as Narcan). If Suboxone strips are melted down and injected intravenously, the small amount of naloxone can trigger severe withdrawal. However, as Nye notes, some patients inject Suboxone, anyway.

With Sublocade, by contrast, misuse of the medication is virtually impossible, due to strict FDA rules that govern the transportation, storage, and administration of the medication.

Sublocade falls under the government’s REMS (Risk Evaluation and Mitigation Strategy) program, which regulates drugs with serious safety concerns.

While Sublocade is quite safe when injected abdominally by a trained provider, the medication can cause serious harm or death if injected into the veins or muscles. The solid that forms after the liquid is injected could cause a dangerous blockage in the arteries, lungs, or other organs.

For these reasons, Sublocade must be ordered through a specialty pharmacy, shipped directly to the provider with the patient’s verbal permission, and administered by a REMS-certified provider.

“We custom order every injection for the patient who it’s intended for, and it’s under lock and key at the clinic,” Nye says.

These safeguards protect the patient, not just from risks to their health but also from judgment they may face when picking up Suboxone from a pharmacy.

“One patient told me, ‘Every time I go to the pharmacy, the pharmacist gives me a look,’ says Nye. “A lot of patients have to deal with the stigma.”

Con: Sublocade isn’t always available right away.

The downside is that the strict Sublocade regulations make it difficult for patients to receive the medication in a timely manner. Some patients enroll in Ideal Option assuming they can receive the medication right away, only to learn that isn’t possible.

“Depending on insurance and location in the country, it can take anywhere from two weeks to two months to get Sublocade,” says Nye.

Until Sublocade arrives, new patients take Suboxone. In fact, even if Sublocade can be acquired in less than a month, FDA regulations require patients to stabilize on buprenorphine strips for at least a week before receiving an injection, though there are some exceptions.

In addition, each insurance company has its own requirements for Sublocade coverage, and some won’t cover the medication at all due to its higher cost.

By contrast, insurance readily covers Suboxone, and patients can receive a prescription from Ideal Option almost immediately.

Nye hopes that more private insurance companies and state Medicaid programs will cover Sublocade, as the benefits — not just to individual patients but also to society — become more evident.

“With more patients taking Sublocade, there will be more money saved on law enforcement and ER visits for overdoses,” Nye says. “Some states are already recognizing that.”

Con: Sublocade can cause a false sense of security.

Despite the many benefits of a monthly injection, Nye cautions that Sublocade patients should not be lulled into a false sense of security. The medication, remarkable though it is, cannot replace the hard work required to progress through the stages of recovery.

“When a patient starts on Sublocade, you can’t just say, ‘OK, you’re good to go.’” Says Nye.

Whereas Suboxone serves as a daily reminder to patients that they’re in recovery — and therefore must actively work on coping and relaxation techniques — patients on Sublocade need to create an alternative system for daily self-check-ins.

For example, Nye suggests Sublocade patients touch the depot and reflect on what it represents.

“I urge them to feel the lump every morning and reassure themselves that they’re OK,” Nye says. “And if they’re not, we need to do a root cause analysis. Maybe the patient needs supplemental Suboxone or to switch their injection dosage or attend counseling that includes early recovery skills and relapse prevention skills.”

Helpful strategies to maintain recovery

Nye also suggests Sublocade patients set daily goals such as “90 for 90” — attending a meeting for 90 consecutive days (12-step, AA, SMART recovery, etc.) — or enroll in an intensive outpatient program (IOP) or one-on-one counseling.

These are helpful strategies for any OUD patient in recovery but are particularly important for those on Sublocade.

Whether a patient takes Suboxone or Sublocade, Nye says, it generally takes about six months of daily recovery work to find your footing and internalize the fact that opioids no longer have power over you.

Both medications can help patients get to that critical six-month mark. “Some people prefer the daily ritual of taking Suboxone and benefit from meeting with their provider more often than once a month,” Nye says, “whereas others do better on Sublocade.”

However, given the staying power of fentanyl, Nye believes Sublocade will become more widely used and more readily covered by insurance.

“We have a growing population of patients addicted to fentanyl,” says Nye. “What I’m finding is, if we can stabilize them quicker, we can save them. Sublocade is a big hammer in our toolbox.”

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To find out more about Ideal Option or to make an appointment, visit www.idealoption.com, call 1-877-522-1275, or email hello@idealoption.net.

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