Tapering off Buprenorphine or Suboxone, Pt 2

In the last post we discussed some of the misconceptions about tapering off opioids. Today we will discuss a couple basic principles, and then describe the approach I recommend for my patients tapering off buprenorphine.
Opioids act at receptors that normally bind endorphins, which are released by neurons in response to a range of stimuli including trauma and rewarding behaviors such as eating a good meal or using addictive drugs. Endorphin pathways elevate mood, reduce sensation of pain, and impact urine production, immune function, intestinal motility, and other bodily functions. Endorphin pathways have a certain baseline activity or ‘opioid tone’ that is directly related to opioid tolerance. When opioid stimulation is greater than one’s tolerance, opioid tone is increased. When opioid stimulation drops below one’s tolerance, opioid tone is reduced, causing withdrawal symptoms.

The goal of any taper off opioids is to recover original or native opioid tolerance. Some people focus on getting rid of the opioid, and even use substances or behaviors to ‘flush buprenorphine from the body’. Products marketed as detox agents have minimal impact on the clearance of buprenorphine or other substances. And even if they could increase the rate of clearance, they would only make detox harder by increasing the severity of withdrawal symptoms. The relatively slow metabolism and clearance of buprenorphine provides a cushion by slowing the loss of opioid tone.

Prolonged use of any opioid changes opioid receptors. The changes are not fully understood but include a decrease in number of receptors and changes in binding properties that reduce receptor sensitivity to opioids, including endogenous opioids (endorphins). Recovery from a state of tolerance takes 2-3 months, and is initiated by reduced opioid tone. Withdrawal symptoms reflect the reduced opioid tone that provokes eventual recovery of native tolerance.

Recovery of native tolerance is the rate-limiting step when tapering off any opioid, including buprenorphine. When the dose of buprenorphine is reduced, the amount of buprenorphine at opioid receptors decreases over the next 5 days and then stabilizes at a lower level. In response, opioid tone (the summation of current flow through opioid receptors) drops below normal. If the dose of buprenorphine is maintained at that level, opioid tone will recover to normal in about 2-3 months. If buprenorphine is suddenly and completely discontinued, opioid tone will decrease to very low levels and cause severe withdrawal that lasts for 2-3 months. If buprenorphine dose decreases more slowly, opioid tone will decrease more slowly, lessening the severity of withdrawal. But it still takes 2-3 months for opioid tone to return to normal. So for any taper, patients must decide whether to decrease their dose quickly and be done in 2-3 months, at the cost of greater withdrawal, or instead to taper more slowly to reduce the severity of withdrawal.

The relationship between buprenorphine dose and opioid activity is linear up to about 2-6 mg. Beyond that point further increases in dose have less impact on opioid tone. The reverse occurs when tapering, so that opioid tone decreases only slightly as dose is reduced from 16 mg per day to 4 mg per day. The non-linear dose/response relationship allows for rapid decreases in dose early in the taper process with limited or no physical withdrawal symptoms. Since the early challenge is mostly psychological, I use the early part of a taper to help assess whether a patient is truly ready to take on the tapering process.

I like to have patients lead the way in tapering off buprenorphine. I’ve found that if I lead and reduce the amount of prescribed buprenorphine for the next month, patients often fail to make reductions and end up out of medication before the end of the month. So instead I ask patients to tell me when they are certain that they are ready to stay at the lower dose.
During a taper, I recommend dosing buprenorphine twice per day. Patients start by removing 2 mg from the evening dose. After at least two weeks 2 mg can be removed from the morning dose. This sequence is repeated at intervals of at least 2 weeks until the total dose is 4 mg per day. In my experience patients who get to that point are usually in a good mental position to begin the second, more difficult part of the taper.

Most people will be able to continue working when opioid dose is reduced by 5% or less every 2 weeks, or 10% every month. That number is a good general guideline when deciding how fast to taper. Suboxone film makes tapering relatively easy. Patients purchase a weekly med organizer, and start the week by opening and stacking 7 films. A scissors or razor is used to cut a millimeter from the end of the stack, and one film is placed in each compartment of the organizer for that day’s dose. When the patient is comfortable with that dose, slightly more is removed for the next week. The process continues every 2-4 weeks, eventually changing to the 2 mg films. I recommend that patients continue tapering until the dose is 300 micrograms (0.3 mg) per day or less before stopping buprenorphine completely. It is fairly easy to guesstimate where to cut the film in order to reduce by 10%; just measure half, then half of that, then half of that.

Buprenorphine tablets, of course, are much harder to divide. Zubsolv did people a favor by coming out with a range of doses, and hopefully other brand and generic manufacturers will eventually follow suit. For now I usually have patients use the tablets to taper as far as possible, using the 2 mg tablets in the lower dose range, and then pay the extra cost for the film for the final month or so. A 12 mg film can be divided into 24 half-milligram pieces without too much effort, so the cost doesn’t have to be prohibitive.

I have had many patients taper successfully off buprenorphine. Fear is common and normal for a number of reasons, but the fear usually gives way to a sense of confidence and optimism when a taper is done correctly.
Things to keep in mind:

  • Be patient. Tapering by too much, or too quickly, causes withdrawal symptoms that lead to ‘yo-yos’ in dose.
  • Buprenorphine products are very potent. A sliver of Suboxone Film may contain enough buprenorphine to harm or kill an animal or small child. Take care to divide the medication in a well-lit setting, and clean up very carefully.
  • Buprenorphine is used to treat pain in microgram doses. If you jump from 1 mg, you will have considerable withdrawal symptoms.
  • If you are still running out of medication early, it is not time to taper off the medication.
  • People on buprenorphine for a year or less have rates of relapse over 90%. In my experience patients are more successful tapering off buprenorphine if they have been on the medication for 2-5 years or more.
  • If you struggle in tapering down to 8 mg, consider going back to your stable dose, waiting 6 months, and trying again.
  • People addicted to opioids often substitute other drugs for their drug of choice. Do not start a new addictive substance in order to get off buprenorphine.

Good luck!

Tapering Off Buprenorphine or Suboxone pt. 1

Many patients taking buprenorphine live in fear of a dark world around the corner where they will have to taper off the medication. They see horror stories on YouTube posted by people who, for some reason, abruptly stopped the medication and kept a video log of their experiences. My own patients sometimes ask, nervously, if I plan to retire some day. Some have asked what they should do if I ever, say, drop dead.

It needn’t be all that bad. Yes, sudden discontinuation of a typical dose of buprenorphine will result in withdrawal symptoms. But if you taper correctly, your body will slowly reset your tolerance without putting you through the wringer. In this post I’ll describe my typical approach to helping a person through that process. But first we should correct some of the misconceptions about buprenorphine and opioid dependence.

It does NOT get harder and harder to stop buprenorphine the longer you take the medication. I have heard that idea over and over in one form or another, and I presume it comes from the experience people have with active addiction where use tends to grow with time, and other facets of life gradually fade away. But the opposite occurs in patients treated with maintenance agents like buprenorphine or methadone, where use of the medication does not trigger a reward or relieve the ‘punishment’ of withdrawal. The conditioning that occurred during active addiction is slowly extinguished, and most people gradually lose the desire to use opioids. I’ve witnessed this process literally hundreds of times over the past 12 years in patients on buprenorphine or methadone. Patients of successful treatment also develop interests and accomplishments that help them avoid returning to opioids. And after a few years away from ‘using friends’, people no longer see themselves as part of the using scene. Patients get to a point where they have too much to lose to get close to that world again.

Opioid withdrawal has physical and psychological dimensions. During short-term detoxes, minor physical symptoms trigger fears that magnify the perception of those symptoms. A bead of sweat on the neck signals that hot flashes, diarrhea, and depression are on the way. Patients who have been away from the cycle of using and withdrawal don’t seem to have as many emotions about their physical symptoms. I see the change very clearly in methadone-assisted treatment, where the minor withdrawal at the end of the day is a big deal to people starting treatment, but a minor inconvenience in patients tapering off methadone after several years of treatment.

Does buprenorphine ‘get in your bones’? YES, of course! Bones are living tissue, so anything in the bloodstream gets in the bones. Glucose gets in your bones. Aspirin gets in your bones. But so what? When you taper off buprenorphine, the buprenorphine in your body will be metabolized and removed. It does not accumulate or stay in bones or other tissues beyond what occurs with other fat-soluble molecules.

Is buprenorphine or Suboxone ‘the hardest opioid to stop’? No. The brain keeps no record of the molecules that pushed opioid tolerance higher. The challenge during a taper is that opioid receptors have become down-regulated by opioid stimulation, resulting in reduced endorphin tone as the opioid is removed. Opioids that leave the body quickly tend to have more-intense discontinuation effects than those that leave more slowly because the latter mimics a taper, where opioid activity decreases over time. The longer half-life of buprenorphine also slightly extends the total period of withdrawal by a few days.

I’ve heard people claim that ‘heroin was much easier to stop’, and rather than tell people what they should think I’ll let them have their opinions on the issue. But that opinion is not supported by studies comparing withdrawal from different opioids. Usually the claim is followed by the comment that ‘with heroin I was fine after 4 days’ or something along that line. But it takes longer for tolerance to reset, after ANY opioid. I suspect that perception comes from the severity of early heroin withdrawal, making subsequent weeks easier by comparison. Again, the brain doesn’t care which opioid you used to take; it only cares that the opioid stimulation that was there is now gone.

In a few days I’ll share the approach I recommend to patients tapering off buprenorphine.

Buprenorphine, Not Subbies

I’ve been writing longer and longer posts on SuboxForum so maybe I need to write more here. This blog archives twelve years of frustration over the ignorance toward buprenorphine, at least until I ran out of steam a year ago. I grew used doctors refusing to treat people addicted to heroin and other opioids. I became used to the growth of abstinence-based treatment programs, even as relapse rates and deaths continued to rise. It isn’t all bad news; I enjoyed the past couple meetings of AATOD, where people openly spoke about medication-assisted treatments without hushed voices. I feel like I’m the conservative one at those meetings!

I don’t remember where I heard first – maybe in an interview with some reporter about addiction- that I was an ‘influencer’ with buprenorphine. The comment surprised me, because from here I don’t see the influence. My supposed influence is from this blog, although I may have changed a couple of minds in my part of my home state among my patients, who had to sit across from me and hear me talk. For an ‘influencer’ I’m not very happy about how many buprenorphine-related things have gone over the years. I still see the same reckless spending of resources, for example. A couple million people in the US abuse opioids, and only a fraction receive treatment.

Those are big things, and anyone reading my blog knows all the big things. I want to write about the little things. The easiest way to have influence is to write about the things that nobody else writes about. After all, that’s what made me an influencer in the first place, back when I had the only buprenorphine blog out there. Here’s what I want to influence: If you’re trying to leave opioid addiction behind, do not call buprenorphine ‘subs’ or subbies.

On the forum I try to keep things real – not in a cool way, but in a medical or scientific way. I want people to use . I know I sound like some old guy frustrated by all of the new words and acronyms on social media. YES, dammit, I AM frustrated by those things! But communication has become so…. careless in the era of Twitter and texting. Find an old book and notice the words and phrases used by educated people 100 years ago. Or look in the drawer at your mom’s house where she kept letters from your dad, or from her friends. Does anyone communicate in sentences anymore?

I’m not crazy (always pay attention when you catch yourself saying that!), so I realize this isn’t the start of a wave (what color would THAT one be?) But I might show a couple people how loose language is used to take advantage of healthcare consumers. In the next post I’m going to show an example of ‘fad-science’ masquerading as alternative medicine, promoting substances that avoid FDA scrutiny by identifying as nutrients and not drugs. Some large scams benefit from the informal attitudes toward health and medicine; attitudes that might encourage more discussion about health, but also lead people to think that medical decisions are as easy as fixing a faulty indicator on the dashboard with the help of a YouTube video. As in ‘I can treat it myself if I can find the medicines somewhere.’

The point is that common talk about medicines is helpful unless it isn’t.
Many people in my area addicted to opioids treat themselves with buprenorphine, either now and then or in some cases long-term. Is ‘treat’ the right word? From my perspective I’d say yes in some cases, and no in others. Last year I took on 4 patients who were taking buprenorphine medications on their own, paying $30/dose, for more than a year. They said (and I believe them) that they hadn’t used opioid agonists for at least that long. I’ve also taken on patients who used buprenorphine but also used heroin, cocaine, and other illicit substances. There is a big difference between the two groups in regard to level of function, employment, relationship status, emotional stability, dental and general health status, and finances. Another difference between them is that people in the first group talk about taking buprenorphine or Suboxone or Zubsolv. Those in the second group talk about finding subbies.

I also have patients in my practice to whom I prescribe buprenorphine, who sometimes talk about subbies, or subs, or ‘vives’, or addies. I correct them and tell them that I have a hard time trusting patients who talk that way. After all, those are street terms. A pharmacist doesn’t say ‘here’s your subs!’

So here’s the rub. Should I discharge these patients? Should I assume from their language that they are part of the street scene, and maybe selling medication I’m prescribing? Or should I just watch them closer and be more suspicious, doubling the drug tests and pill counts? Should I tell the police?
No, of course not. I took it that far to make a point about slippery slopes, and the struggle to find a foothold while sliding.

But I will continue to correct them, and let them know that their words create a certain impression. Getting that point across would be enough influence for one day!

Missing the Point of Buprenorphine Treatment

A forum reader wrote about concerns over a partner on buprenorphine. Her concerns pointed out a common misperception about the goals of treatment of opioid use disorder using buprenorphine, or using methadone for that matter.

Her question, amended for privacy:
I married the love of my life. He is still he love of my life but has been an addict for 15 of them. Our children have been greatly affected by his addiction. He made promise after promise that he was clean, and I dove back in with complete faith time after time only to get burned.

His addiction started with recreational pills increasing over time, but now he is abusing Suboxone. He was taking up to 12 mg depending on the day, but no pain pills for the last year. I suggested a Suboxone doctor and a plan to get off, and my husband called one and was able to get right in.

At the visit the doctor did a half ass intake and called in a prescription for an 8 mg tab for induction. After induction they called in prescription for 20 mg/day. My husband stayed with 4 mg once a day and was “blah” in the afternoon and irritable but not physically sick. On his next visit to the doctor he was proud, but when he told the doctor he had only take 4mg in the mornings she got angry. She told him she wouldn’t see him anymore if that’s what he was going to do. He asked how long he would be on it and she wouldn’t give any kind of answer. I asked again before we left and she snapped at me.

I see a profound change in him after each time we see her and she tells him to take more. We walked away last time with another prescription for 16 mg a day which is just about double what he’s been taking for the last year and a half. So my question is, how does it make sense to treat someone taking 8 mg as their addiction with the same medication at double the dosage? Since seeing her he has decided he needs to take it more than once a day as well as up the dosage. Is this right? Is it right to treat Suboxone addiction with Suboxone? A heroin addict isn’t treated with more heroin and a pill addict isn’t treated with more pills. While I understand the concept of treating his original pill addiction with Suboxone, I am having a very hard time wrapping my head around what’s happening.

Me again…
The writer raises interesting questions. Regarding the ‘drug for a drug’ questions, buprenorphine has significant pharmacologic differences from heroin or pain pills. Those differences, including the long half-life and ceiling on agonist effects, allow the medication to create a level degree of mu-receptor agonism across the dosing interval. Tolerance to that level mu agonism allows patients on the medication to feel ‘normal’ throughout the day, or at least normal from an opioid standpoint.

But her broader point provides an example of the basic misunderstanding many people have about medication assisted treatment, in focusing on the same short-term goals that their addicted loved ones have focused on: controlling the dose of opioid and tapering off. That goal is natural, of course; anyone who loves a person addicted to opioids wishes and hopes that the person will reverse the using behavior and climb down from opioid use. Those hopes are bolstered by ads for rapid detox, even as studies show that detox is mostly useless.

My response to her:
I would not be concerned about increasing the dose of buprenorphine, because there is no increase in effect after a dose of about 8 mg per day. A higher dose might reduce mild withdrawal symptoms at the end of the dosing interval, and sometimes provides a reduction in cravings through a placebo effect.

So why increase? Because the goal with buprenorphine treatment is to put cravings into remission for a considerable length of time. If your husband is still having cravings as he gets by on 8 mg, then his dose is not high enough. Buprenorphine is a safe medication that is used as a tool to extinguish the conditioning that was part of your husband’s addiction.

One of my patients saw a different buprenorphine physician for years, and her dose was constantly lowered over the past year. She would run out of medication after 24 days each month and then go without for 6 days, craving opioids and experiencing wtihdrawal during that time. In some ways, her entire time in treatment was a waste. She could boast, I suppose, that she was prescribed less buprenorphine over time. But in most ways she is just as far from stopping opioids as when she entered treatment, still lying to her husband, lying to her doctor, and feeling ashamed of herself. All of those things keep her addiction in the dark, where it stays active.

When I started treating her my goal was to promote legitimate behavior. I increased her dose to 12 mg per day, from 8 mg. After a month she still ran out early, So I raised the dose to 24 mg per day. Now, after 6 months, she has taken the medication as prescribed. Her focus on buprenorphine is going down, as we want it to do. She isn’t lying, and she isn’t craving pain pills or buprenorphine. My goal is for her to take the medication like she would take a vitamin or blood pressure pill, without any special attention or interest.

How long will we do this? I can’t say now. We know from research that the longer a person stays on medication, the less risk of relapse after stopping. I don’t like to push anyone off buprenorphine, because I’ve seen so many people who have relapsed after being pushed off by their former doctors. I find that many people eventually decide that the time has come to taper off buprenorphine, and those efforts are usually successful. From my perspective, people forced to taper off buprenorphine do not generally do well. That perspective is just an opinion, but an opinion based on treating 800 people with buprenorphine over the past 11 years.

Opinions aside, the goal is not about getting off opioids as fast as possible. Your husband can accomplish that in a couple weeks with a remote hotel room and a bottle of clonidine, or a couple weeks in jail. But those experiences rarely lead to prolonged abstinence, and they sometimes precede overdose, when people return to using with a lower tolerance.

I can’t tell whether your husband’s doc is on the right track or not– but she might be. She is a better doctor telling you that she can’t give a time estimate, than a doctor telling you he will be off in 3 months. Ideally, your husband will be in a state of ‘remission’– on a dose of buprenorphine that virtually eliminates interest in opioids– for a year or more. He can taper for some of that time, but the taper should be slow enough that he doesn’t return to using. If he returns to active use, he starts over in many ways.

Try to drop the focus on ‘how much’ or ‘how long’. Those things are not important; what is important is to get his interest back on you and the family, not on buprenorphine or other opioids. That will be easier if you let him know that he has your support, even if he takes a medication, and even if he needs that medication for a long time. You would want the same from him if you ever needed a medication for hypertension, diabetes, or anything else.

Ten Gripes of Buprenorphine Doctors

I recently gave a lecture to medical students about opioid dependence and medication assisted treatment using buprenorphine, methadone, or naltrexone. I was happy to see their interest in the topic, in contrast to the utter lack of interest in learning about buprenorphine shown by practicing physicians. In case someone from the latter group comes across this page, I’ll list a few things to do or to avoid when caring for someone on buprenorphine (e.g. Suboxone).

1. Buprenorphine does NOT treat acute pain, so don’t assume that it will. Patients are fully tolerant to the mu-opioid effects of buprenorphine, so they do not walk around in a state of constant analgesia. Acute pain that you would typically treat with opioids should be treated with opioids in buprenorphine patients. Patients on buprenorphine need higher doses of agonist, usually 2-3 times greater than other patients. Reduce risk of overuse/overdose by providing multiple scripts with ‘fill after’ dates. For example if someone needs opioid analgesia for 6 days, use three prescriptions that each cover two days, each with the notation ‘fill on or after’ the date each will be needed.

2. Don’t say ‘since you’re an opioid addict I can’t give you anything’. There are ways to provide analgesia safely. If you do not provide analgesia when indicated, your patient will only crave opioids more, and may seek out illicit opioids for relief. Unfortunately nobody will criticize you for leaving your patient in pain, but they should!

3. Don’t blame the lack of pain control on laws that don’t exist, for example “I’d like to help you but the law won’t let me.” Patients deserve honesty, even when the truth makes us uncomfortable. We get paid ‘the big bucks’ for tolerating the discomfort that sometimes comes from frank discussions with our patients.

4. Don’t assume your patient can or cannot control pain medications. If a patient has been stable on buprenorphine for years, he/she may have a partner or family member who you can trust to control pain medications. Some patients stable on buprenorphine can control agonists used for acute pain, but I wouldn’t stake my life, or theirs, on that ability. A useful compromise is to prescribe enough pain medication to cover 1-2 days of analgesia on each of several prescriptions, each with a ‘fill after’ date, to reduce the amount of agonist controlled by the patient at one time.

5. Don’t tell your patients that ‘opioids don’t work for chronic pain.’ I see stories on such great medical sources as the ‘Huffington Post’ explaining that ‘opioids never help chronic pain’. In reality, your patients know that opioids DO treat chronic pain, so they will consider you a liar or an idiot if you clam they don’t. The challenge is explaining the risk/reward equation to your patients, and explaining why treating chronic pain with opioids often leads to greater problems, as the risk/benefit equation is changed by tolerance.

6. I know this will cause heads to explode, but don’t assume that chronic pain is always less severe than acute pain. What if your patient’s chronic pain is worse than the typical pain after cholecystectomy or ACL repair? Most doctors would gasp at the idea of recovering from major surgery without opioids. What if the pain from failed back syndrome is worse?! I have had a few patients who, I’m certain, experience a great deal of suffering, and have gone so far as to have brain or spinal cord implants to get relief. I’m not arguing that we treat chronic pain in the same way as acute pain. But we shouldn’t jump to the conclusion that chronic pain isn’t severe enough to warrant opioids in order to dismiss those complaints more easily.

7. Don’t tell your patient to stop taking buprenorphine unless you’ve talked with the doctor who is prescribing that medication, and realize that the doctor you are calling knows more about buprenorphine and addiction than you do.

8. Don’t ask patients ‘how long are you going to take that stuff’ or criticize patients’ use of buprenorphine medications. Likewise psychiatrists shouldn’t tell patients scheduled for knee arthroscopy that the procedure is controversial, or talk patients out of hernia surgery.

9. Don’t assume that the doctor prescribing buprenorphine knows what YOU are doing. Too often patients will tell me about surgery that they failed to discuss in advance, even calling about pain hours after getting home from a procedure they failed to mention. Some people seem to believe that doctors regularly collaborate on their care, even though the opposite is closer to the truth.

10. Don’t assume that unusual or atypical symptoms come fromo buprenorphine. One truism of medicine is that doctors tend to blame unexplained symptoms on whatever medication they know the least about. Fevers of unknown origin, mental status changes, or double vision are not ‘from the buprenorphine!’

Those are the gripes at the top of my list. Did I miss one of yours? Or for patients, have you suffered from breakdowns in the system?

Addendum: 11. When treating post-surgical pain in buprenorphine patients, choose one opioid and stick with it. What often happens is that doctors will use one opioid, say morphine… and when nurses call a few hours later to say the patient is still screaming, they change to a different opioid, then another after that. As a result, the patient is placed on insufficient doses of several opioids, rather than an adequate dose of one medication.

There are two critical issues in treating such patients effectively. First, providing pain relief comes down to competition at the mu receptor. A certain concentration of agonist in the brain and spinal fluid will out-compete buprenorphine and provide analgesia. You cannot get there by adding other opioids together. If you use oxycodone for an hour and then change to dilaudid, you are starting over. Instead, choose one drug, preferably something that can be given intravenously, and stick with it. Morphine is not a good option btw, because of the low potency and histamine releasing properties of that drug.

Second, remember that analgesia and respiratory depression travel together, both mediated by the mu receptor. Anesthesiologists know this principle well… opioid medication can be titrated to respiratory rate, providing that the medication is given IM or IV. If a patient is breathing 28 times per minute, he/she is in pain. If the patient is breathing 6 times per minute, pain is not a problem, and the patient should be monitored for respiratory depression and possible overdose. When treating pain, doctors should aim for a respiratory rate of 14-18 breaths per minute, making sure that the medication is actually getting into the bloodstream (the risk comes when patients are given SQ injections or oral doses of narcotic that enter the bloodstream later, causing toxic blood levels).