First Posted 12/15/2013
People know my bias—that buprenorphine is best-considered a chronic, perhaps life-long treatment for a chronic, life-long disease. That said, I am aware of how many people out there are convinced that they need to be ‘off everything,’ no matter the misery opioids have caused in their lives. I don’t get it; my perspective over the years has been seeing obituaries of patients who were doing great on buprenorphine or Suboxone for years, until well-intentioned relatives convinced them that they weren’t really clean.
But I’ve written all of this before. For those of you who are still intent on stopping buprenorphine, I’ll share my observations after watching hundreds of people stop the medication—some intentionally, and some before going back to H for some crazy reason.
First off—there is NO truth to the idea that ‘the longer you take it, the harder it is to stop.’ The idiots who peddle that line are the same people who are on and off buprenorphine, or perhaps who have run out of doctors willing to see them and now hoping that company will join their misery. The opposite is true. The patients who have done the best are the people who stayed on buprenorphine or Suboxone for at least 2-3 years, and came to a point where they just knew it was time to stop. The ones that have done well—stayed clean—are the ones who made gains during their time on buprenorphine. They got educated. They got promoted. They started families in a responsible manner (i.e fell in love first, and then had the family).
I’ve seen so many people stop Suboxone after 3 months, 8 months, or a year—and what I’ve seen mirrors the studies that show 90% relapse rates within one year of stopping buprenorphine.
I’ve developed a set of indicators that are associated with maintaining abstinence after buprenorphine. In very-rough order of importance, they are:
- Taking buprenorphine once per day or at MOST twice per day, not in response to depression, fatigue, emptiness, insomnia, or urge, but completely ‘by the clock’—as they would take blood pressure medication.
- Having month after month with no extra calls reporting lost or stolen buprenorphine, having no ‘very bad weeks where everything went wrong that forced them to take a little extra’.
- No use of intoxicants, especially for treating mood or anxiety—i.e. the ability to live ‘life on life’s terms.’
- Age over 30. Not sure why—but I have my theories. Age brings wisdom, persistence of intent, insight into emotions, and the realization that life is temporary and precious.
- No history of depression or anxiety. Not always controllable, unfortunately.
- Stable job, stable finances, and stable relationship, and preferably one or two hobbies.
- Complete loss of using contacts, and NO immediate access to opioids (no spouse on pain pills or Xanax; no dealer calling every few days).
- Absence of a chronic pain condition- or acceptance that one will have to tolerate one’s pain.
- Being on a regular exercise schedule.
- The recognition that opioids kicked the snot out of them, multiple times—and a strong fear of relapse.
People who lack one or more of these items should strongly re-evaluate a decision to stop buprenorphine.
When someone wants to stop taking buprenorphine and I’ve educated that person about the numbers and risks, my next step is to ask the person to cut from 16 mg of buprenorphine (if on that much) to 8 mg. That change done correctly will cause no physical withdrawal, but creates enough mental pressure to separate those who are ready from those who are not.
Remember at this point that all of these things are used in my own practice; they are not intended to direct people who are not my patients, but rather to stimulate discussion with your OWN doctor(!)
The method I usually recommend is for the person to go to twice per day dosing—8 mg AM and 8 mg PM, and then change to 8 mg AM and 6 mg PM for two weeks, then to 6 mg/6 mg for two weeks, then 6 mg/4 mg for two weeks, then 4mg/4 mg. If the person can do that without any problems, I am willing to help with the taper.
I usually have patients to make small reductions at their own pace every few weeks. The goal is to move slowly; one common misstep is to make a reduction before arriving at a stable blood level from the last reduction. A dose should be maintained for at least a couple weeks before dropping lower.
Most people benefit from more-frequent dosing during tapering, since the effective half-life of buprenorphine is shortened when blood levels drop below the ‘ceiling level.’ I’ve had some patients claim to do better dosing 3 times per day during tapers. My only concern about dosing that frequently is the risk of returning to conditioned addictive behavior. I suppose the other issue is that more-frequent dosing requires smaller doses, that are more difficult to keep consistent. The 2 mg film is very helpful for tapering at lower levels, can with a razor or hobby-knife.
Patients on buprenorphine for pain treatment can avoid violating the Hamilton Act and progress down a series of Butrans patches—a process that is technically illegal for non-pain patients. The biggest patch releases about 0.5 mg of buprenorphine per day, which seems like a big step from 2 mg of oral buprenorphine until you remember that only 30% of an oral dose is absorbed. So 2 mg of oral buprenorphine yields about 0.7 mg of buprenorphine in the bloodstream—close to the amount delivered by the largest Butrans patch.
It is illegal to taper opioid addicts using Butrans, according to the Harrison Act. I realize that the situation is not fair… but sometimes Presidents create laws, even put their names on them, thinking the law is a good idea… and then the future ends up showing what a bad, bad idea the law was. Just speaking of Harrison, of course…
When patients fail a taper by using opioid agonists or returning to a higher dose of buprenorphine, I suggest they go back to a comfortable dose, and try again in a year. The hardest part of tapering is mental, but the physical symptoms are nothing to sneeze at. When tapered slowly, the physical withdrawal from buprenorphine isn’t all that much worse than having a bad cold. The goal is to stay in the game, hour after hour (after hour).
I recently met with a patient who stopped ‘cold turkey’ from 16 mg, who shared his experience in detail. He worked every day in a factory job, and managed to stay at work throughout the entire process. He swore by the 5-hr energy drinks, and said that they kept him working on the worst of days. His symptoms peaked at 11 days, and at 3 months he felt fully recovered. He carried pictures of his kids, and looked at them every time he felt a hot flash or was stuck on the commode.
I believe that he will do well because he knows that addiction is truly cunning, baffling, and powerful, and understands that he must always be alert for some crazy, cocky idea to enter his thought process. One interesting thing in this particular patient was that the entire time he went through withdrawal, he never experienced cravings. He had been on buprenorphine for a number of years, and just felt ‘done.’
Finally… most of us were brought to addiction by our best ideas. Sobriety requires CHANGE, and change is not comfortable or pleasant. Nobody wants to attend his/her first meeting. And everyone who loves meetings has many, many days when meetings are the last thing they want to do… but they go anyway. THAT is what change is all about.