Stopping Suboxone

I recently received a question about stopping Suboxone (buprenorphine)…. I deleted the message but I remember the bulk of it, and I have a copy of my response. I thought that someone else out there may find it useful, so here it is:

The question:

I have decided to go off Suboxone after that was recommended to me by almost everybody. My doctor told me to taper off by going down to 2 mg per day, and then take 2 mg every other day, then every third day, and stopping after I get to every 4th day. I followed those instructions and I am taking it every other day, but I am now getting sick every other day. Is this a good way to stop Suboxone, or do you recommend another way?

My response:

I’m not certain who is giving you advice. More and more, the standard of care is to keep people on buprenorphine for at least a year, and many people stay on ‘remission treatment’ indefinitely– just as we do for other chronic illnesses. There is no evidence or truth to the idea that ‘it is harder to stop buprenorphine the longer you take it’; tolerance does not increase after reaching a plateau, usually in a month or so, and I have found that patients are more successful at stopping buprenorphine the further they get from the period of active use. There is no significant toxicity from the medication when it is taken properly; it is far safer than medications used to treat other illnesses, such as hypertension, elevated cholesterol, asthma, diabetes, or arthritis– let alone other potentially fatal illnesses like cancer.

If you DO go off buprenorphine, the method you described won’t generally work because of the pharmacokinetics of the drug. The plasma half-life of buprenorphine is 2-5 hours, but the elimination half life is over 30 hours. The volume of distribution of the drug increases with dose because of dose-dependent protein binding. Finally, the ceiling effect creates a non-linear relationship between blood level and pharmacologic effect. The practical result of these factors is that larger doses of buprenorphine produce opioid effects that last longer than smaller doses. A typical buprenorphine pain dose of 50-100 micrograms lasts for 6-8 hours, but in the super high doses used for addiction (8 mg equals 8000 micrograms), the opioid effects last much longer- allowing for once per day dosing.

As the dose is lowered, the effects of buprenorphine become shorter in duration. So the person tapering buprenorphine need to not only take smaller amounts each day, but must also divide that daily amount into two, then three, then maybe even four doses to avoid withdrawal symptoms at the end of the dosing interval.

On my forum, SuboxForum, people discuss the ‘liquefied taper method’– a method that I believe I was the first to describe, where a tablet of Suboxone is dissolved in a small amount of water, and doses are administered by drop from a medicine dropper or TB syringe. Any small medicine bottle and the included dropper can be used. I would suggest taking the time to calculate the microgram per milliliter concentration, and using the dropper to dose known amounts.  A TB syringe is more accurate, as it has the amounts marked on the side. For this purpose, a ‘cc’ is the same as an ‘ml’. There are 1000 micrograms per milligram (mg). I’ll leave the rest of the calculations to you!

Another option might be to use ‘Butrans’, a buprenorphine skin patch, after tapering to a low sublingual dose. The biggest patch releases 500 micrograms (or 0.5 mg) per day, and there are a couple smaller sizes with the smallest patch releasing 0.1 mg per day or 100 micrograms. One could taper down to a quarter of an 8 mg tab per day, and then change to the 0.5 mg patch. That sounds like a big drop, but only a small percentage of the sublingual dose of buprenorphine is absorbed– some estimates as low as 15% of the dose. By that estimate, a 2 mg sublingual dose of buprenorphine would be comparable to 0.5 mg of transdermal buprenorphine.

I wrote Butrans might be used because under current law, doctors cannot prescribe Butrans to treat addiction—and I assume that includes tapering off buprenorphine. Federal law that allows for use of controlled substances to treat opioid dependence (DATA 2000)—an exception to the Harrison Act— only allows use of medications that are indicated for opioid dependence. At the present time, Butrans is indicated for treating pain, and not for treating addiction. By my understanding of the law, doctors can use Butrans to taper patients off buprenorphine only if the indicated use for the buprenorphine is any condition other than addiction.

But again, do give some thought to whether you should be stopping buprenorphine, as the relapse rate for opioid dependence is, unfortunately, very high.