What are the current American Society of Addiction Medicine (ASAM) guidelines for weaning a patient off Suboxone (buprenorphine/naloxone) who has been stable on 8mg once daily for 6 months?

ASAM Guidelines for Weaning Off Suboxone

The American Society of Addiction Medicine (ASAM) recommends a gradual taper of 10% of the original dose per week for patients who have been stable on Suboxone (buprenorphine/naloxone) for 6 months at 8mg daily. 1

Assessment Before Initiating Taper

Before beginning a taper from Suboxone, evaluate:

• Stability of recovery (minimum 6 months recommended)
• Patient's readiness and motivation for discontinuation
• Risk factors for relapse
• Support systems in place
• Presence of comorbid mental health conditions

Tapering Protocol

For a patient stable on 8mg daily Suboxone for 6 months:

1. Initial Phase (Weeks 1-4):

   • Reduce by 10% (0.8mg) per week
   • Week 1: 7.2mg daily
   • Week 2: 6.4mg daily
   • Week 3: 5.8mg daily
   • Week 4: 5.2mg daily

2. Middle Phase (Weeks 5-8):

   • Continue 10% reductions from original dose
   • Week 5: 4.6mg daily
   • Week 6: 4.0mg daily
   • Week 7: 3.6mg daily
   • Week 8: 3.2mg daily

3. Final Phase (Weeks 9-10):

   • Slow taper further at lower doses
   • Week 9: 2.4mg daily
   • Week 10: 1.6mg daily
   • Week 11: 0.8mg daily
   • Week 12: 0.4mg daily, then discontinue

Monitoring During Taper

• Use the Clinical Opiate Withdrawal Scale (COWS) to monitor withdrawal symptoms 1
• Assess for:
  • Mild withdrawal (COWS 5-12): Continue taper
  • Moderate withdrawal (COWS 13-24): Consider pausing taper
  • Severe withdrawal (>25): Consider returning to previous dose

Withdrawal Management

For breakthrough withdrawal symptoms during taper:

• Non-pharmacological approaches:

  • Regular exercise
  • Stress reduction techniques
  • Adequate sleep hygiene
  • Cognitive behavioral therapy 1

• Adjunctive medications for symptom management:

  • α2-agonists (clonidine or tizanidine) for autonomic symptoms
  • Loperamide for gastrointestinal discomfort
  • Trazodone or mirtazapine for insomnia 1

Special Considerations

• If withdrawal symptoms become intolerable, pause the taper and maintain the current dose for 1-2 weeks before resuming 2
• For patients who experience significant withdrawal at lower doses (below 2mg), consider even slower tapers of 0.2mg per week 1
• If withdrawal symptoms persist despite slow tapering, consider extended-release buprenorphine injection to facilitate final discontinuation 3

Post-Discontinuation Care

• Schedule frequent follow-up visits (weekly for first month)
• Provide overdose prevention education
• Dispense take-home naloxone kit
• Continue psychosocial support
• Monitor for signs of relapse for at least 3 months 1

Important Caveats

• Studies show high rates of taper failure and relapse when discontinuing buprenorphine 4
• Only 13.3% of patients in one study successfully switched to alternative treatment, with 66.7% stopping their tapers due to withdrawal symptoms, drug use, or psychiatric instability 4
• A shorter 7-day taper showed better short-term outcomes than a 28-day taper, but both had poor long-term success rates (12-13% opioid-free at 3 months) 5
• The target dose may not be zero; some patients whose regimens have been tapered to elimination may benefit from resumption at lower doses 2

Remember that the decision to taper should be carefully considered, as maintenance therapy has shown better long-term outcomes for opioid use disorder than complete discontinuation in many cases.