What is a recommended taper schedule for a patient starting at 2mg of Suboxone (buprenorphine/naloxone) per day?

Suboxone (Buprenorphine/Naloxone) Tapering Schedule for Patients on 2mg Daily

For patients starting at 2mg of Suboxone daily, a decrease of 10% of the previous dose every 2-4 weeks is recommended as the optimal tapering schedule to minimize withdrawal symptoms and maximize successful discontinuation. 1

General Tapering Principles

• A slow taper is essential to minimize withdrawal symptoms which can include drug craving, anxiety, insomnia, abdominal pain, vomiting, diarrhea, diaphoresis, mydriasis, tremor, and tachycardia 1
• Tapers may need to be paused and restarted when the patient is ready, especially when reaching lower doses 1
• Success should be measured by patient progress rather than rigid adherence to a schedule 1
• Withdrawal symptoms should be actively monitored and managed throughout the tapering process 1

Recommended Tapering Schedule for 2mg Starting Dose

• Week 1-4: Maintain at 2mg daily to ensure stability 1
• Week 5-8: Reduce to 1.8mg daily (10% reduction) 1
• Week 9-12: Reduce to 1.6mg daily (10% reduction) 1
• Week 13-16: Reduce to 1.4mg daily (10% reduction) 1
• Week 17-20: Reduce to 1.2mg daily (10% reduction) 1
• Week 21-24: Reduce to 1.0mg daily (10% reduction) 1
• Week 25-28: Reduce to 0.8mg daily (10% reduction) 1
• Week 29-32: Reduce to 0.6mg daily (10% reduction) 1
• Week 33-36: Reduce to 0.5mg daily (10% reduction) 1
• Week 37-40: Reduce to 0.4mg daily (10% reduction) 1
• Week 41-44: Reduce to 0.3mg daily (10% reduction) 1
• Week 45-48: Reduce to 0.2mg daily (10% reduction) 1
• Week 49-52: Reduce to 0.1mg daily (10% reduction) 1
• Week 53-56: Extend dosing interval to every other day at 0.1mg 1
• Week 57-60: Extend to every third day at 0.1mg, then discontinue 1

Adjusting the Taper

• If withdrawal symptoms become severe, return to the previous well-tolerated dose and slow the taper further 1
• For patients who have been on Suboxone for years, consider an even slower taper of 10% per month 1
• More rapid tapers might be needed in cases of severe adverse events, but these carry higher risk of withdrawal and relapse 1

Managing Withdrawal Symptoms

• Protracted withdrawal symptoms may include dysphoria, irritability, insomnia, and anhedonia even months after discontinuation 1
• Adjunctive medications may be used to manage specific withdrawal symptoms:
  • For anxiety/agitation: Clonidine 0.1-0.2mg every 6 hours as needed 1
  • For insomnia: Short-term trazodone 50-100mg at bedtime 1
  • For muscle aches: Acetaminophen or NSAIDs 1
  • For GI symptoms: Loperamide for diarrhea, ondansetron for nausea 1

Important Considerations and Pitfalls

• Studies show that most patients attempting to taper off opioid agonist therapy are not successful, so set realistic expectations 2
• Research indicates that shorter tapers (e.g., 7 days) may actually show better short-term outcomes than longer tapers (28 days), but long-term success rates are similar and generally low 3
• Avoid setting arbitrary time limits for completing the taper; individualize based on patient response 1
• Never abruptly discontinue Suboxone due to risk of withdrawal 1
• Provide close monitoring and support throughout the tapering process 1
• Consider offering naloxone for overdose prevention, especially for patients with history of overdose or substance use disorder 1

Follow-up Schedule

• Evaluate patients within 1-4 weeks of starting the taper and after each dose reduction 1
• More frequent follow-up (every 1-2 weeks) is recommended during the initial phase of tapering 1
• Continue regular monitoring throughout the entire tapering process and for several months after discontinuation to assess for protracted withdrawal and relapse 1