How To Taper 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. This post describes How To Taper Off Buprenorphine or Suboxone.

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.