What is the best way to taper off Butrans (buprenorphine)?

From the Guidelines

Tapering off Butrans (buprenorphine) should always be done under medical supervision with a gradual reduction in dosage over several weeks or months, with a recommended taper rate of 10% per month or slower, as suggested by the CDC clinical practice guideline for prescribing opioids for pain - United States, 2022 1.

Key Considerations for Tapering

• The tapering plan should be individualized based on patient goals and concerns, and clinicians should collaborate with the patient on the tapering plan, including decisions on how quickly tapering will occur and when pauses in the taper might be warranted 1.
• Patient agreement and interest in tapering is likely to be a key component of successful tapers, and clinicians should establish goals with the patient for continued opioid therapy and maximize pain treatment with nonpharmacologic and nonopioid pharmacologic treatments as appropriate 1.
• Clinicians should follow up frequently (at least monthly) with patients engaging in opioid tapering, and team members (e.g., nurses, pharmacists, and behavioral health professionals) can support the clinician and patient during the ongoing taper process 1.

Tapering Approach

• The best approach typically involves decreasing the patch strength by 5-10 mcg/hour every 1-2 weeks, depending on the current dose, with a goal of minimizing withdrawal symptoms and signs of opioid withdrawal 1.
• During the final stages of tapering, the doctor might switch the patient to the buprenorphine buccal film (Belbuca) or tablets for more precise dosing control at lower doses 1.
• Throughout the tapering process, it's essential to monitor for withdrawal symptoms such as muscle aches, insomnia, anxiety, or gastrointestinal distress, and the doctor may slow the taper schedule or prescribe supportive medications like clonidine for specific symptoms 1.

Important Reminders

• Abruptly stopping LTOT is not recommended, except for reasons of diversion or extreme patient danger, and clinicians should not abandon patients or make “cold” referrals to other clinicians 1.
• High dose should be considered a risk factor but not determinative for taper, and clinicians should seek patient consent and collaboration during tapering 1.
• Clinicians should diagnose and treat opioid use disorder (OUD) when present, and document treatment response throughout the tapering process 1.

From the Research

Tapering Off Butrans (Buprenorphine)

• The best way to taper off Butrans (buprenorphine) is not directly addressed in the provided studies, but we can look at the general principles of tapering off psychiatric drugs and opioid withdrawal management for guidance 2, 3, 4, 5.
• A highly accepted clinical approach for treatment discontinuation is to gradually reduce doses over time 3.
• Hyperbolic tapering by exponential dose reduction appears to be a promising strategy for psychiatric drug discontinuation, including opioid withdrawal management 2, 3.
• Slower tapering (over months or longer) of antipsychotics and other psychiatric medications is associated with a lower relapse rate than quicker tapering (weeks) 4.
• For opioid withdrawal management, buprenorphine is more effective than clonidine or lofexidine in terms of severity of withdrawal, duration of withdrawal treatment, and the likelihood of treatment completion 5.
• The rate of dose tapering may affect treatment outcome, but the available evidence is uncertain and divergent, suggesting that multiple factors may influence the response to the rate of dose taper 5.
• Transdermal buprenorphine patches (BuTrans) have been shown to be effective and well-tolerated for managing chronic pain, including osteoarthritis pain 6.

Key Considerations

• Gradual dose reduction is recommended to minimize withdrawal symptoms and prevent relapse 2, 3, 4.
• Hyperbolic tapering by exponential dose reduction may be a useful approach for tapering off Butrans (buprenorphine) 2, 3.
• Individual factors, such as the initial treatment plan and the presence of underlying medical conditions, may influence the response to tapering 5.
• Close monitoring and adjustment of the tapering schedule as needed are crucial to ensure a safe and effective discontinuation of Butrans (buprenorphine) 3, 4, 5.