How do I safely stop taking buprenorphine (Suboxone) and start taking opioids under medical supervision?

Transitioning from Buprenorphine to Full Opioid Agonists

For perioperative pain management requiring moderate-to-severe pain control, discontinue buprenorphine 72 hours before the procedure and initiate short-acting opioid agonists, with a clear plan for buprenorphine reinitiation once acute pain resolves. 1

Critical Context: This is NOT Recommended for Opioid Use Disorder

Never abruptly stop buprenorphine in patients being treated for opioid use disorder (OUD), as this dramatically increases relapse risk and potential overdose mortality. 1 The guidance below applies specifically to perioperative pain management scenarios where temporary transition is medically necessary.

Timing of Buprenorphine Discontinuation

Standard Protocol

• Discontinue buprenorphine 72 hours (3 days) before surgery or the need for full opioid agonists 1
• For high-pain procedures, some protocols recommend 3-5 days of discontinuation 1
• Buprenorphine's long half-life (24-44 hours) means receptor occupancy persists well beyond the last dose 2

Tapering Options

Two approaches exist for stopping buprenorphine before surgery:

Slow taper (preferred for lower relapse risk):

• Taper over 2 weeks before surgery 1
• Remain buprenorphine-free for 72 hours before the procedure 1

Rapid taper (when time is limited):

• Abrupt cessation 3 days before surgery 1
• Higher risk of withdrawal symptoms and relapse 1

Managing the Transition Period

Preventing Withdrawal During the Gap

• Consider replacing buprenorphine with methadone if relapse risk is high during the buprenorphine-free period 1
• Use short-acting opioid agonists to manage withdrawal symptoms if they emerge 1
• Monitor closely for signs of relapse to illicit opioid use 1

Opioid Requirements After Buprenorphine

• Expect opioid requirements similar to opioid-tolerant patients 1
• Higher-than-normal doses of full agonist opioids will be needed for adequate analgesia 1
• Consider patient-controlled analgesia (PCA) with higher dosing parameters 1
• For intermediate-to-high pain procedures, consider ICU admission for respiratory monitoring given high opioid doses required 1

Multimodal Analgesia is Essential

Maximize non-opioid analgesics to reduce total opioid requirements:

• NSAIDs 1
• Acetaminophen 1
• Membrane stabilizers (gabapentinoids) 1
• Regional anesthesia techniques 1
• Local anesthetic infiltration by surgeon 1

Reinitiation of Buprenorphine

Critical Safety Point

Establish a clear plan for buprenorphine reinitiation BEFORE stopping it 1

Timing

• Restart buprenorphine once the patient no longer requires narcotic analgesics for acute pain 1
• Coordinate reinitiation with the patient's buprenorphine provider 1
• Typically occurs 2-4 days post-surgery once acute pain is controlled 1

Reinitiation Protocol

• Patient must be in mild-to-moderate opioid withdrawal before restarting buprenorphine to avoid precipitated withdrawal 1
• Verify withdrawal symptoms using a validated opioid withdrawal scale 1
• Initial dose typically 2-4 mg, reassess in 30 minutes 1
• Target maintenance dose of 16 mg daily is sufficient for most patients 1

Alternative Strategy: Continue Buprenorphine

For patients on ≤12 mg sublingual buprenorphine daily, continuation through the perioperative period is an alternative approach 1

This strategy involves:

• Continuing baseline buprenorphine dose 1
• Dividing the daily dose to every 6-8 hours for better analgesic effect 1
• Adding short-acting full agonist opioids at higher-than-normal doses for breakthrough pain 1
• Understanding that buprenorphine doses >10 mg daily may partially block opioid analgesics 1

This continuation strategy is only appropriate for low-to-moderate expected pain; it is NOT recommended for high-pain procedures 1

Critical Warnings

Never Abandon Patients

• Do not make "cold referrals" to other clinicians who have not agreed to accept the patient 1
• Abrupt cessation without support increases overdose risk 1
• The prescriber is obligated to either provide safe tapering, obtain agreement from another physician, or offer alternative treatment 1

For OUD Patients Specifically

• The decision to temporarily stop buprenorphine for surgery must be weighed against very high relapse risk 3
• Most patients with OUD who discontinue buprenorphine relapse to more dangerous opioids 1
• Buprenorphine used as medication-assisted treatment for OUD should generally NOT be discontinued to comply with dose guidelines 1