How long does Sublocade stay in your system?
Sublocade stays in your system for months, not days. The prescribing information gives the apparent terminal half-life of buprenorphine after a Sublocade injection as 43 to 60 days, and a drug is not gone until several half-lives have passed.
The same document puts the rest plainly. Once a patient has reached steady state, which takes four to six monthly injections, buprenorphine may be detectable in blood and urine for twelve months or longer after the last shot. While the medicine works for about a month between injections, after the last one expect therapeutic levels for two to five months on average, depending on the dose.
Mark Leeds, D.O. hears this question for four different reasons. The person asking has stopped or missed an injection, or a drug test is coming, or they want to switch to naltrexone, or they are facing surgery. While the facts are the same in all four cases, what to do with them is not. Which one is yours?
Why is the half-life measured in days instead of hours?
Buprenorphine itself did not change. When you take Suboxone, or any daily buprenorphine film or tablet dissolved under the tongue, the label gives a half-life of 24 to 42 hours, which is why a missed dose is felt by the next morning.
Sublocade puts the same molecule inside a liquid that turns solid under the skin, usually of the abdomen, though the thigh, buttock, or back of the arm will do. That solid lump, known as a depot, dissolves slowly and lets buprenorphine out a little at a time. So, the half-life you are reading about is the half-life of the depot, not of the drug.
An analogy that might help is the ice in a picnic cooler. Ice cubes keep the cooler cold for an hour, and an hour after you stop adding them, the cooler is warm. One solid block keeps it cold for days, and keeps doing so after you have stopped bringing ice, until the last of it is gone.
While this is not a perfect analogy, it explains the number. The liver, the drain at the bottom of the cooler, clears buprenorphine at the same speed it always did. The block is still melting.
What happens when you stop Sublocade?
At first, nothing happens, and that is the point, because levels do not fall off a cliff on day 29. They drift down over months, and the label tells doctors that any withdrawal will be delayed, and to watch for it for several months after the last injection.
Patients have described the end of Sublocade as a long, low fade rather than the crash they remembered from stopping a daily opioid. While some notice a few weeks of poor sleep and restless legs at night in the second or third month, others notice nothing they can name.
If you missed an appointment, the label says that a delay of up to two weeks is not expected to affect your treatment. And, if you have just had an injection and regret it, the most recent depot can be surgically removed under local anesthesia within 14 days, which is rarely done but worth knowing.
Yet, the fade raises an obvious question. If the level falls a little every day, all by itself, for months, is that not exactly what a taper is supposed to do?
Can the slow fade work as a taper?
This is an excellent question, and the answer is that it can. In fact, it is the idea behind the Sublocade taper for getting off of Suboxone.
The hardest part of any buprenorphine taper is the bottom. A film cannot be cut into the tiny fractions the last stretch calls for, so the final steps are the biggest ones, at the point where the nervous system is most sensitive to change.
Fortunately, the depot does that part by itself. Once the last injection is in, the level falls a little every day for months, in steps smaller than any strip could be cut, with no decisions to make and no dose to forget. Before the last one, a doctor may space the injections farther apart, or step down from the 300 mg dose to the 100 mg dose, so the final fade starts lower.
Unfortunately, there are no formal studies of Sublocade used this way. The label approves it as maintenance, not as a taper. Beyond the mechanism, what doctors know about the fade comes from watching patients go through it, and one patient’s fade is not a study.
A depot also cannot be adjusted once it is under the skin. While that is the whole appeal, it also means that if the fade is too fast, there is no film to hold in reserve unless your doctor has prescribed one. That is a conversation to have before the last injection, not after it.
How long will you test positive for buprenorphine after Sublocade?
Will Sublocade show up on a drug test? Which test? For how long? For a test that is looking for buprenorphine, a very long time. The label’s own figure is twelve months or longer after the last injection once you have reached steady state, in urine as well as blood.
Most drug tests are not looking for it. A routine five-panel test checks for marijuana, cocaine, amphetamines, PCP, or phencyclidine, and opiates, and the opiate line reacts to morphine and codeine, not to buprenorphine. Buprenorphine shows up only when someone orders the specific buprenorphine test, which treatment programs do on purpose, and some employers and courts do as well.
Unfortunately, a court or a rehab program that tests for buprenorphine is often the same one that wants you off of it before it will call you finished, on a schedule set by a contract rather than by a receptor. Most of them mean well. Still, the depot does not read contracts.
So, what should you do about a test? Keep taking your medication. Sublocade is a prescribed treatment, and a positive result with a prescription behind it is a complete explanation. A drug test cannot tell a patient with a prescription from a person who bought the drug on the street. That is what the medical review officer is for, so give the officer the prescription.
Of course, stopping your medication to pass a test would not even work, since the tail is a year long. One caution, though. A result that is positive many months after your last injection can look, to someone who does not know the pharmacology, like a fresh start. So, ask your doctor for a letter with the date of the last injection.
Can you switch from Sublocade to naltrexone or Vivitrol?
Yes, and the waiting is the whole problem. Naltrexone, or Vivitrol in its monthly injected form, is an opioid antagonist, meaning that it blocks the receptor without turning it on. Give it to someone who still has an opioid on those receptors and you get precipitated withdrawal, a sudden withdrawal that the Vivitrol label warns can be severe enough to require a hospital stay.
That label asks for a minimum of 7 to 10 days opioid-free before the first Vivitrol injection, and warns that people coming from buprenorphine may be vulnerable for as long as two weeks. While those numbers were written for daily buprenorphine, with its half-life of a day or two, they were not written for a depot with a half-life of two months.
So, after Sublocade the wait is longer, and nobody can read it off a calendar. It depends on the dose, on how many injections you had, and on you, and the only honest way to time it is with testing, a naloxone challenge if your doctor uses one, and patience. The Vivitrol label lists a positive urine screen for opioids as a reason not to give the shot at all.
A person who wants to be done with opioids entirely, with a blocker in place while the brain heals, is making an excellent choice. Just do not let anyone rush the middle part. Whether to choose Sublocade or Vivitrol at all is a different decision, best made before the first injection rather than after the sixth.
What about surgery and pain control while the depot is active?
Buprenorphine holds on to the opioid receptor and does not let go easily. That grip is what makes it safe, and it is also what makes a surgeon’s usual pain medication work poorly on top of it. With a film, you could hold a dose. With a depot, there is nothing to hold.
The label’s instruction to doctors is plain. Use pain control that is not an opioid wherever possible, and, when an opioid is truly needed, use a strong one that binds the receptor tightly, expect to need higher doses than usual, and watch closely for slowed breathing.
What this means for you is a conversation before the surgery, not during it. Tell the surgeon and the anesthesiologist the date of your last injection, and ask your buprenorphine doctor to speak with them. While most surgical teams have handled daily buprenorphine, fewer have handled the depot.
In an emergency, none of this is a reason to wait. Go to the emergency room, say that you have Sublocade on board, and let them manage the pain with the depot in place. They can, and they should.
What about Brixadi?
Brixadi is the other long-acting buprenorphine injection, in a weekly form and a monthly form. Its label gives an apparent terminal half-life of 3 to 5 days for the weekly shot and 19 to 26 days for the monthly one, against Sublocade’s 43 to 60.
The tail is shorter to match. After steady state, the Brixadi label expects detectable buprenorphine for about one month after the weekly product and about four months after the monthly one, against Sublocade’s twelve months or longer.
While Sublocade is the longer ramp for a person who wants the slow fade, weekly Brixadi clears in a fraction of the time for a person who wants a short tail before naltrexone or a test. Which one makes the better buprenorphine taper depends on which of those two people you are. Neither is better on its own. One is simply longer.
What are the risks while Sublocade is in your system?
The serious one is breathing. Buprenorphine has a ceiling on its opioid effects, including how far it can slow breathing, which is a large part of why it is safer than a full opioid. While the ceiling holds when buprenorphine is taken alone, it does not protect you when a benzodiazepine or alcohol is added, and the label is blunt about it: the combination can cause severe drowsiness, breathing problems, coma, and death.
If someone on Sublocade cannot be woken, or their breathing is slow or has stopped, call 911. Naloxone is still worth giving while help is on the way, and the label advises keeping it in the house for exactly that reason.
People sometimes hear that the ceiling makes withdrawal milder. It does not, because the ceiling is about breathing and about getting high, and what makes the end of Sublocade gentle is the slow fade.
The everyday side effects are the ones buprenorphine always has, constipation, nausea, headache, vomiting, and tiredness, plus an itchy or sore lump at the injection site. The lump is supposed to be there. It is the block of ice.
Does needing a plan to stop mean you are addicted to it?
No. Buprenorphine causes physical dependence, as every opioid taken daily does, and physical dependence is not addiction. Physical dependence is the receptors adjusting to a drug that is always there. It is treated with a taper, not with a program.
As for misuse, a depot placed under the skin by a doctor, in a clinic, once a month, is about as hard to misuse as a medication gets. While a bottle of strips can be lost, shared, or sold on the way home, a shot you cannot take home cannot.
The depot does its part on its own, a little less each day, for as long as it takes. Your part is to make the plan for the end before the end arrives, with your doctor, and then to let the block melt.
Dr. Leeds prescribes buprenorphine for patients in Florida.
Dr. Leeds prescribes buprenorphine films and tablets for patients in Florida, with visits by telemedicine. He does not offer Sublocade or Brixadi injections as a service. A depot has to be placed by a clinician and cannot be sent home in a bottle, so a patient who wants the injection needs a prescriber who does; he can advise on the choice, and on getting off a depot, in a consultation.
The plan for the end, whether that is long-term maintenance, a gradual taper, or a switch to naltrexone, is made with the patient, at the patient’s pace, and written down in advance rather than improvised. Anyone with questions about Sublocade, or about getting off of buprenorphine, can contact Dr. Leeds through the form on this website.
This article is educational. It is not medical advice, and reading it does not create a doctor-patient relationship. Decisions about starting, continuing, or tapering any medication should be made with your own physician.
About the physician
Mark Leeds, D.O. is an osteopathic physician providing concierge telemedicine care focused on medication dependence treatment and deprescribing, including buprenorphine treatment for opioid dependence. He serves on the medical advisory board of the Benzodiazepine Information Coalition and hosts The Rehab Podcast on the Mental Health News Radio Network. Medical management is available for patients in Florida.
