When should Suboxone (buprenorphine/naloxone) be discontinued for a patient with opioid use disorder?

From the Guidelines

Suboxone (buprenorphine/naloxone) should be discontinued for a patient with opioid use disorder only after careful consideration and planning, ideally when the patient has achieved stable recovery and is ready for a gradual taper, as supported by the most recent guidelines 1. When considering discontinuation of Suboxone, it is essential to weigh the benefits and risks of continued therapy, taking into account the patient's individual circumstances, including their stability in recovery, duration of treatment, and personal goals.

Key Considerations

• The decision to discontinue Suboxone should be made collaboratively between the patient and healthcare provider, with a focus on minimizing risks and maximizing benefits 1.
• A slow, structured tapering process over several months is recommended, with dose reductions of 10-25% every 1-2 weeks as tolerated, to minimize the risk of withdrawal symptoms and relapse.
• Patients should have strong psychosocial support systems in place, stable housing, employment, and mental health before attempting discontinuation.
• Medical supervision is essential throughout the tapering process to monitor for withdrawal symptoms, cravings, and relapse risk.

Tapering Process

• The tapering process should be individualized and tailored to the patient's needs, with regular assessments and adjustments as needed.
• If withdrawal symptoms or cravings become severe during tapering, the dose should be temporarily stabilized or increased before attempting further reductions.
• Patients should be educated about the increased overdose risk following discontinuation due to reduced opioid tolerance.

Maintenance Therapy

• Some patients may benefit from indefinite maintenance therapy, as premature discontinuation carries significant risks of relapse and overdose 1.
• The decision to continue maintenance therapy should be based on the patient's individual needs and circumstances, with regular assessments and adjustments as needed.

From the FDA Drug Label

Buprenorphine hydrochloride should not be abruptly discontinued in a physically-dependent patient [see DOSAGE AND ADMINISTRATION] If buprenorphine hydrochloride is abruptly discontinued in a physically-dependent patient, a withdrawal syndrome may occur, Physical dependence may not occur to a clinically significant degree until after several days to weeks of continued use.

The decision to discontinue Suboxone (buprenorphine) for a patient with opiate use disorder should be based on careful evaluation of the patient's physical dependence and risk of withdrawal syndrome.

• Physical dependence can develop after several days to weeks of continued use.
• Withdrawal syndrome may occur if buprenorphine is abruptly discontinued in a physically-dependent patient. It is recommended to follow the guidance in the DOSAGE AND ADMINISTRATION section of the drug label for tapering the dose to minimize the risk of withdrawal syndrome 2.

From the Research

Discontinuation of Subxone for Opiate Use Disorder

• The decision to discontinue Subxone (buprenorphine) for a patient with opiate use disorder should be made on a case-by-case basis, considering the individual's unique circumstances and treatment goals 3.
• Research suggests that longer duration of treatment with buprenorphine is associated with better outcomes, including reduced risk of overdose and improved social connections 4, 5.
• However, discontinuation of buprenorphine treatment is often accompanied by adverse health outcomes, including increased risk of overdose, emergency department visits, and inpatient hospitalizations 5.
• A study found that patients who were retained on buprenorphine for 15-18 months had significantly lower odds of adverse outcomes, including emergency department visits and inpatient hospitalizations, compared to those retained for 6-9 months 5.
• The risk of acute care service use and overdose remains high following buprenorphine discontinuation, regardless of treatment duration 5.
• Clinicians should use a shared decision-making approach with patients to determine the best course of treatment, including the decision to discontinue buprenorphine 3.
• It is essential to consider the patient's "recovery capital," including their social support, motivation, and coping skills, when making decisions about discontinuing buprenorphine treatment 3.
• Opioid withdrawal symptoms can be a significant barrier to discontinuation, and clinicians should be prepared to manage these symptoms and provide support to patients during the discontinuation process 6.