Long-Acting Injectable MAT Options Compared
The injectable MAT category has three options now. Sublocade and Brixadi are both extended-release buprenorphine, just with different dosing flexibility. Vivitrol is extended-release naltrexone. The buprenorphine injectables and the naltrexone injectable are pharmacological opposites and they fit different patients. Lumping them together as "monthly shots" misses the point.
| Attribute | Sublocade | Brixadi | Vivitrol |
|---|---|---|---|
| Active ingredient | Buprenorphine | Buprenorphine | Naltrexone |
| Drug class | Partial opioid agonist | Partial opioid agonist | Full opioid antagonist |
| FDA approval | 2017 for OUD | 2023 for OUD | 2006 for AUD, 2010 for OUD |
| Frequency options | Monthly only | Weekly or monthly | Monthly only |
| Dose options | 100mg or 300mg | 8mg, 16mg, 24mg, 32mg weekly; 64mg, 96mg, 128mg monthly | 380mg only |
| Injection site | Subcutaneous abdomen | Subcutaneous (multiple sites) | Intramuscular gluteal |
| Pre-treatment requirement | 7 days on transmucosal buprenorphine | Single dose of transmucosal buprenorphine sufficient | 7 to 10 days fully opioid-free |
| Storage | Refrigerated | Refrigerated | Refrigerated |
| REMS program | Yes - Sublocade REMS | Yes - Brixadi REMS | No |
| Sticker price | ~$1,580 per shot | ~$1,200 per monthly dose, varies by strength | ~$1,500 per shot |
The two-camp split
Sublocade and Brixadi are agonist medications. They activate opioid receptors partially, eliminating withdrawal and reducing cravings. They fit patients who are still in active opioid use disorder or who have detoxed but still need pharmacological craving support.
Vivitrol is an antagonist medication. It blocks opioid receptors. It does nothing for cravings directly and produces no opioid effect. It fits patients who have already detoxed and want to stay opioid-free without taking an opioid medication to do it.
Sublocade vs Brixadi
Sublocade was first to market in 2017. Monthly only, two doses (100mg and 300mg), abdominal injection. The 300mg dose is the standard maintenance after two 300mg loading doses.
Brixadi launched in 2023 with weekly and monthly options at multiple strengths. The weekly option is useful for patients who are unstable or want shorter commitment intervals during early treatment. The induction is also easier: a single transmucosal buprenorphine dose, observation, then immediate Brixadi injection. Sublocade requires a full week of stable transmucosal buprenorphine before the first depot.
Why Vivitrol does not compete directly
Vivitrol's induction is fundamentally different from either buprenorphine injectable. To start Vivitrol, the patient must be 7 to 10 days fully opioid-free. To start Sublocade or Brixadi, the patient must be on buprenorphine. These are mutually exclusive states. A patient who is the right candidate for Sublocade is not the right candidate for Vivitrol that day, and vice versa.
Where Vivitrol does compete is downstream. A patient who has been stable on Sublocade for a year and wants to taper off opioid medication entirely might transition to Vivitrol as a final step. A patient leaving residential treatment opioid-free might choose between starting Sublocade (with the agonist support) or Vivitrol (with the cleaner pharmacology).
Who fits which option
Sublocade is the strongest evidence-based option for patients with active opioid use disorder who can tolerate a week of transmucosal induction. Brixadi has the easiest induction and the most flexible dosing, useful for patients in chaotic life circumstances or those who want weekly accountability. Vivitrol is for patients who have detoxed and want a non-opioid maintenance option.
Cost and Medicaid
All three are covered by every state Medicaid program. All three have manufacturer copay assistance for commercial insurance patients. Cash prices range from $1,200 to $1,600 per month. The financial decision is rarely the deciding factor at the patient level.