What is the recommended protocol for discontinuing Suboxone (buprenorphine/naloxone) titration?

Discontinuing Suboxone (Buprenorphine/Naloxone) Titration Protocol

Suboxone should be gradually tapered over weeks to months to minimize withdrawal symptoms, with dose reductions of approximately 25% every 1-2 weeks, and slower reductions at lower doses. 1

Recommended Tapering Protocol

Initial Assessment

• Evaluate patient's readiness for discontinuation
• Assess risk of relapse to opioid use
• Screen for depression and other mental health conditions that may impact discontinuation 1

Standard Tapering Schedule

1. Initial Phase: Reduce daily dose by 25% every 1-2 weeks until reaching 8mg daily
2. Middle Phase: Once at 8mg daily, reduce by 2mg every 1-2 weeks until reaching 2mg daily
3. Final Phase: At 2mg daily, reduce by 0.5mg every 1-2 weeks until complete discontinuation 1

Slower Tapering for Sensitive Patients

• For patients experiencing significant withdrawal symptoms, slow the taper to 10% reductions every 1-2 weeks
• Consider dividing the daily dose into 2-3 doses (every 8-12 hours) during tapering to maximize analgesic effect and minimize withdrawal 1

Alternative Approaches

Extended-Release Buprenorphine Method

For patients struggling with traditional tapering:

• Consider transitioning to extended-release buprenorphine injection (100mg) as a final step
• This approach can mitigate prolonged withdrawal symptoms after discontinuation 2, 3

Conversion to Longer-Acting Agent

• For patients experiencing severe withdrawal symptoms, consider temporarily switching to a longer-acting agent like fluoxetine before final discontinuation 4

Managing Withdrawal Symptoms

Symptom Management

• Use non-opioid adjunctive therapies for withdrawal symptoms:
  • NSAIDs for pain and discomfort
  • Clonidine for autonomic symptoms (0.1-0.2mg every 6 hours as needed)
  • Antiemetics for nausea/vomiting
  • Sleep aids for insomnia 5, 1

Monitoring During Tapering

• Assess for withdrawal symptoms using Clinical Opioid Withdrawal Scale (COWS)
• Monitor for signs of relapse to opioid use
• Evaluate pain control if Suboxone was used for pain management 1, 6

Important Considerations

Warning Signs to Slow Tapering

• Moderate to severe withdrawal symptoms (COWS score >12)
• Drug-seeking behaviors or cravings
• Psychological distress or instability 6

Reinstatement Protocol

If withdrawal symptoms become intolerable:

• Reinstate Suboxone at the previous stable dose
• Stabilize for 1-2 weeks
• Resume tapering with smaller increments and longer intervals between reductions 1, 4

Caution

• Abrupt discontinuation can precipitate significant withdrawal syndrome characterized by restlessness, lacrimation, rhinorrhea, perspiration, myalgia, and mydriasis 6
• Physical dependence may not be clinically significant until after several days to weeks of continued use, making gradual tapering essential 6

Post-Discontinuation Support

• Continue regular follow-up appointments for at least 3-6 months
• Maintain access to naloxone due to increased overdose risk after discontinuation
• Consider ongoing counseling or support groups to prevent relapse 1

Remember that patients who have been on Suboxone maintenance therapy have a higher risk of relapse to opioid use after discontinuation, making careful monitoring and support crucial throughout this process.