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. Presenting how to stop buprenorphine or Suboxone, Pt 2
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 at least twice per day because of the loss of the ‘ceiling effect’ below doses of about 8 mg/day. Below 8 mg/day, doses will last for less time, the lower the dose. 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 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.
Linda · August 15, 2018 at 1:11 pm
My tapering off is going well. I know l like routine so l changed my routine of taking suboxone first thing in the morning( like l have for years) to not taking at all until l feel a mild withdraw symptom then l will take a small piece of a 2 mg strip.
I have tried and will keep trying to prolong that habit of doing that and wait out any discomfort..
Like l stated before l use to take 14 2mg strips per month now after 6 months l am down to 3 strips per month. With my next doctor visit l will direct doctor to prescribe 2 per month.
My goal is to be off completely by end of this year if l can’t oh well l will keep trying.
I am going to take my time but l will succeed.
Michael Palladini · August 16, 2018 at 12:14 pm
Please comment on your documentation of tapering, as the Suboxone film is not FDA approved/scored for variable dosing. Thank you
Jeffrey Junig MD PhD · August 17, 2018 at 10:36 am
This blog post is the documentation. As I’ve written a number of times, there is a big difference between peer-reviewed research and internet advice. Both have their place and limitations. One cannot do a randomized, double-blind ‘study’ of the best way to taper off buprenorphine, as the tapering process is not amenable to that experimental design. Even if it were, an academic addictionologist working with residents or post-docs would not be able to duplicate the approach that I take and recommend, i.e. where I have a close clinical relationship with individuals, communicate by text or email during the process, and make individual adjustments in the process depending on circumstances.
FDA approval is determined by a number of things beyond clinical utility. Suboxone film was not FDA-approved for induction for many years, but was used in the vast majority of inductions. Nobody is going to pay millions of dollars for FDA-approval of ‘variable dosing’ until someone makes the business decision to produce taper packs or to boost sales by recommending such tapers. I’m aware that people argue whether buprenorphine is evenly distributed in the film or whether the thickness varies across the length of a strip, but those arguments have little relevance for several reasons. First, the long half-life of buprenorphine causes one day’s blood level to be derived from several days or more of dosing, so those slight variations, if present, will have little impact on the tapering process. And second, the psychological challenges associated with tapering are as great, or nearly as great, as the physical symptoms caused by a reduction in dose of 5-10% per month.
And of course there are many clinical approaches that are not ‘FDA-approved’. FDA approval is required for marketing of medications for certain uses, so the manufacturer cannot market or recommend taper strategies, just like the makers of gabapentin can’t market the drug for bipolar disorder even though many psychiatrists prescribe it for that or other non-indicated reasons.
Locust · August 17, 2018 at 5:30 am
Hello Dr. Junig Thanks for the info .Everything you have said in both articles has been true in my case . I enter into day 12 feeling like the worst is behind me that said I can honestly tell people I functioned through the whole process.(I jumped from 2mg and was on that dose for 5 years)I’m not going to say it has been easy it takes commitment and especially patience.I don’t feel like I’m completely out of the woods as I still feel like I’ve lost some strength especially in my legs and that could be due to my inconsistent sleep however each day I’m sleeping a little better. Again Patience ,stay busy and enjoy your senses as they come back slowly the first one I noticed was taste .But others will come back as well some might surprise you as you may not have even noticed they have been suppressed .God bless and good luck to all who plan to get off the Subs .
Jeffrey Junig MD PhD · August 17, 2018 at 10:41 am
Thanks for sharing your experience. When I went through detox almost 20 years ago, the fatigue was the worst, longest-lasting symptom. It is hard to remember specific dates from that long ago, but I do remember going to the YMCA after two months and still noticing significant weakness and fatigue… and I remember feeling almost super-powered when I left treatment, after 10-11 weeks. I see similar experiences in people tapering off methadone or buprenorphine; it takes 2-3 months for fatigue to go way, for appetite and taste to return, and to regain healthy sleep. Patience, patience, patience…
Timothy C. · September 12, 2018 at 6:20 pm
I was in drug rehab through the month of June for a longstanding addiction to methamphetamine and kratom (in the last 9 years I had used kratom daily for 7 of them). I also used potent heroin every day for thirty days before going to rehab.
My addiction psychiatrist recommended Suboxone treatment immediately after being released from rehab after 25 days. She said she considered kratom an opiate because of its action, and said she thought using Suboxone was more methodologically sound with more research behind it then using kratom for maintenance therapy, especially because kratom comes from unknown sources and is not consistent in strength (I have used kratom from trusted sources for many years and could dispute this…)
I trusted her and began using Suboxone the day I was released from rehab. I shortly stabilized at a 4mg daily dose, but the side effects really bothered me – not only the destruction of my libido, but I was getting aural hallucinations before bed that were disturbing and keeping me from sleep; the sweating was difficult to deal with; I felt I was having water retention; there were some pretty tough sleep disturbances and nightmares.
I tapered on my own after 8 weeks of being on 4mg Suboxone. I thought I had done due diligence with an ambitious taper program, but I did it much too fast. It just didn’t feel fair to have to take a longer period to taper than I had actually been on the medication!
I cut my dose to 2.8 mg daily in one jump, waited 7 days, then cut it again to 2 mg daily. It was a difficult withdrawal process. It has been 12 days since I cut to 2 mg and I am still having significant withdrawal effects, mainly hot flashes, restlessness, anxiety, and insomnia with a feeling of continuous tension. I expect all of this to go away eventually, a few more weeks hopefully. However, the voices and sounds I was hallucinating before bed went away almost completely, and most of the sweating is gone (except for bursts with the hot flashes occasionally, especially under stress/exertion). Sex drive seems to be at least alive, if not great, but better than dead, like it was.
I had been planning to cut further, but I saw my psychiatrist again this week. She was unperturbed about me reducing my dose on my own. She did say she thought I should stay on the 2mg dose for at least a year before considering going off Suboxone in order to prevent relapse.
I have personal ideas about maybe getting off Suboxone and going back to kratom, using measured doses and frequency as a maintenance medication. I haven’t really voiced these to her, as I know she would be against it. If I stay off heroin and meth, I think I’d be okay, but I can also see that this is probably mere justification to go back to kratom instead of Suboxone. Usage of that botanical medicine doesn’t seem to have the same side effects as Suboxone, although it has it’s own issues.
I am in an outpatient program that specifically tests me for kratom (among everything else). I have not used any substances in 100 days. I will be starting at a major university in January as a junior, and have school funding tied to my success in chemical dependency therapy, so I don’t see myself using kratom anytime soon. Yet, I have some put back for some time in the future. Addictive thinking, I know.
Hopefully my current withdrawal effects will stop eventually. I plan to stay at the 2mg dose for a while, I guess. I’m tempted to cut it to 1.8 soon, but that’s just masochistic and perhaps self-sabotage.
Derrick · September 14, 2018 at 6:28 pm
I am new on this site. I am 69 years old. I smoked my first joint in 1966 and have been drinking and doing drugs pretty much ever since.
This past year, not sure what happened but when the dust cleared, l lost my home , $70,000
In savings, and pretty much my family. God bless my son, I am living in his basement, he is mad at me, like the rest of them, but they should be.
I was reading what the Dr on this site ((I don’t really recall his name)is saying. I think all you people should listen to him.
I am on Saboxone now, and things are getting clearer for me. I am slowly getting what’s left of my life together. I used to build houses, now I am working part time at Home Depot. You know what, that’s OK. I want to survive this and I think Saboxone is my way.
I don’t understand all this crying about the withdrawals, nothing is worse than the life I was living.NOTHING. This Dr.has reminded us of this.
I don’t really know how my story will end, but you, especially the young people should listen to this guy.
JB · November 4, 2018 at 3:50 am
Thank you so much for this forum. I appreciate the valid information, given in a professional , easy to understand way. There’s so much out there about Suboxone that is scary. I am so glad I found this forum with explanations and answers that appear to be valid and well researched.
Michelle · December 5, 2018 at 10:27 am
This is a great documentation of the tapering process. I took 4mg a day for 6 months, 2mg a day for a month, 1mg a day for a month, and then down to .5mg a day for about 3 weeks. I am currently at day 4 without subs. I didn’t sleep last night, I am extremely restless, lots of aches that I’m not used to, and my head is pounding. I’m in the worst of it.
I do believe in myself, and my ability to kick this. I’m nervous, but excited. I feel like I have been withdrawing for over a month now, and I am so ready to be over this! I’ve been doing this on my own, as I’m not prescribed the medicine. My boyfriend is prescribed 16mg a day, and only needs 6-8mg.. I’ve considered getting my own prescription if I can’t do this on my own… i can’t risk a relapse. This was very encouraging, though. I feel pretty confident.
Jeffrey Junig MD PhD · December 31, 2018 at 1:33 pm
Good luck! Just stick with it!
Anonymous · September 19, 2022 at 2:31 pm
Hi Doc. Have you had anyone taper off with success who’s been on suboxone for 14 years or more? Or have you had anyone on it this long?
J Junig MD PhD · September 19, 2022 at 7:07 pm
I have started about 800 people on buprenorphine and have 270 patients on it now. Most of the rest have tapered off, most of those after taking it for at least 5 yrs (I’ve been prescribing it for 15 years). The key is first to START. People develop so much fear… but it will be easier than you think, I promise – IF you go slow. Start with 2 mg reduction every 2 weeks, until you get to 8 mg per day. Then go SLOWER. Never reduce if you are still having symptoms from the last reduction.
You CAN do it, but most people talk about it for years and never get started, Take away a tiny part, and wait until you feel confident that you are OK. Then a tiny bit more.