What happens if you stop someone on Suboxone (buprenorphine/naloxone)?

Abrupt Discontinuation of Suboxone Can Lead to Severe Withdrawal Symptoms and Risk of Relapse

Stopping Suboxone (buprenorphine/naloxone) abruptly can cause significant withdrawal symptoms, increased risk of relapse to illicit opioid use, and potential overdose death, and should never be done without medical supervision. 1

Withdrawal Symptoms and Timeline

When Suboxone is discontinued abruptly, patients will experience withdrawal symptoms that can be severe and prolonged due to buprenorphine's long half-life:

Acute Withdrawal (Days 1-7)

• Restlessness, lacrimation, rhinorrhea, perspiration, chills, myalgia, and mydriasis
• Irritability, anxiety, backache, joint pain, weakness
• Abdominal cramps, insomnia, nausea, anorexia, vomiting, diarrhea
• Increased blood pressure, respiratory rate, and heart rate 2

Protracted Withdrawal (Weeks to Months)

• Dysphoria, irritability, insomnia, anhedonia
• Vague sense of being unwell that can persist for months 1

Risks of Abrupt Discontinuation

Abrupt discontinuation of Suboxone carries significant risks:

• Increased risk of relapse to illicit opioid use due to withdrawal discomfort
• Overdose risk is heightened due to loss of tolerance
• Psychiatric complications including suicidal ideation or behavior
• Emergency department visits and hospitalizations 1

Proper Discontinuation Protocol

If discontinuation of Suboxone is necessary, it should follow these evidence-based guidelines:

1. Gradual tapering is essential - ideally reducing by 10% of the previous dose rather than equal decrements 1
2. Extended timeline - tapering should occur over months, not days or weeks
3. Close monitoring for withdrawal symptoms, cravings, and psychological distress
4. Adjunctive medications to manage specific withdrawal symptoms:
   • Clonidine for autonomic symptoms
   • Non-opioid analgesics for pain
   • Anti-diarrheal medications as needed
   • Sleep aids for insomnia

Special Considerations

Extended-Release Options

For patients struggling with traditional tapering, extended-release buprenorphine injection may facilitate discontinuation by mitigating prolonged withdrawal symptoms 3

Psychosocial Support

Patients undergoing Suboxone discontinuation should be referred for behavioral therapies to:

• Reduce withdrawal-related anxiety
• Increase treatment retention
• Provide coping strategies for cravings 1

Warning Signs Requiring Immediate Attention

• Severe psychological distress or suicidal ideation
• Inability to maintain hydration due to gastrointestinal symptoms
• Signs of relapse to illicit opioid use

Common Pitfalls to Avoid

1. Abrupt discontinuation is never appropriate with opioids, including Suboxone, except in extreme cases like confirmed diversion or serious medical toxicity 1

2. "Cold referrals" to clinicians who have not agreed to accept the patient are considered unacceptable medical care 1

3. Underestimating withdrawal severity - buprenorphine withdrawal can be more prolonged than withdrawal from full agonist opioids due to its long half-life

4. Failing to address fear of withdrawal - this is often a primary reason patients continue opioid therapy and must be taken seriously 1

5. Overlooking that pain itself may be a withdrawal symptom - increased pain during withdrawal may be new or amplify preexisting pain 1

By following these evidence-based approaches to Suboxone discontinuation, clinicians can minimize patient suffering and reduce the risk of relapse and associated harms.