Suboxone (Buprenorphine/Naloxone) Tapering Protocol
A slow, individualized tapering approach of 10% per month or slower is the most effective method for tapering Suboxone to minimize withdrawal symptoms and reduce risk of relapse. 1, 2
Pre-Tapering Assessment and Planning
- Verify current dose and duration of Suboxone treatment
- Screen for concurrent benzodiazepine use (dangerous combination)
- Assess for opioid use disorder (OUD) using DSM-5 criteria
- Evaluate for anxiety, depression, and other mental health conditions that may worsen during tapering
- Discuss tapering goals, timeline, and potential withdrawal symptoms with patient
- Create a written taper agreement outlining the collaborative process
Tapering Schedule Options
Standard Taper (Recommended for Most Patients)
- Reduce dose by 10% of the previous dose per month
- Example for 16mg/day starting dose:
- Month 1: 14.4mg/day
- Month 2: 13.0mg/day
- Month 3: 11.7mg/day
- Continue this pattern until reaching the smallest available dose
Slower Taper (For Long-Term Users or Anxious Patients)
- Reduce dose by 5% of the previous dose per month
- More gradual approach for patients on long-term therapy (≥1 year)
- Particularly useful for patients with high anxiety about tapering
Micro-Taper (For Final Stages)
- When reaching the smallest available dose (2mg film):
Managing Withdrawal Symptoms
Common Withdrawal Symptoms
- Anxiety, irritability, insomnia, dysphoria
- Muscle aches, abdominal cramps, nausea, diarrhea
- Diaphoresis, mydriasis, tremor, tachycardia
Adjunctive Medications
- α2-Adrenergic Agonists: Clonidine (0.1-0.2mg every 6 hours) for sympathetic hyperactivity 1, 2
- Loperamide: For gastrointestinal symptoms
- Sleep aids: Trazodone or mirtazapine for insomnia
- Pain management: Scheduled acetaminophen (not exceeding 3000mg daily)
- Anti-anxiety: Hydroxyzine or gabapentin (non-benzodiazepine options)
Monitoring and Follow-Up
- Schedule monthly visits during the tapering process
- Monitor for:
- Withdrawal symptoms
- Changes in mood or suicidal thoughts
- Cravings or return to substance use
- Pain control
- Adjust taper rate based on patient response:
- If withdrawal symptoms are severe, pause taper or return to previous dose
- If patient is tolerating well, continue with planned schedule
Special Considerations
- Pause points: Plan for pauses in the taper at 8mg, 4mg, 2mg, and 1mg to allow neuroadaptation
- Psychological support: Incorporate cognitive behavioral therapy, mindfulness, and stress management techniques
- Exercise: Regular physical activity can help manage withdrawal symptoms
- Avoid rapid tapers: Tapering too quickly increases risk of withdrawal, relapse, and treatment failure 1
- Never abruptly discontinue: This can lead to severe withdrawal and increased risk of returning to illicit opioid use 1, 2
When to Slow or Pause the Taper
- Significant withdrawal symptoms that interfere with daily functioning
- Major life stressors or changes (job loss, relationship changes, housing issues)
- Development or worsening of mental health symptoms
- Patient request due to feeling overwhelmed
Common Pitfalls to Avoid
- Tapering too rapidly: Can lead to withdrawal, treatment failure, and seeking alternative opioid sources 1, 2
- Inadequate symptom management: Failure to address withdrawal symptoms increases taper failure risk
- Insufficient follow-up: Regular monitoring is essential to adjust the taper as needed
- Rigid adherence to a schedule: Flexibility based on patient response is crucial for success
- Cutting films into quarters: Research shows poor content uniformity when cutting Suboxone films into quarters 3
By following this structured, patient-centered approach to Suboxone tapering, you can minimize withdrawal symptoms and optimize the chances of successful discontinuation while prioritizing patient safety and comfort.