Can a Patient Stop Suboxone?
A patient should never abruptly stop Suboxone, as sudden cessation can precipitate severe withdrawal symptoms, increase risk of relapse to illicit opioid use, and potentially lead to overdose death if the patient returns to opioids with reduced tolerance. 1
Critical Safety Principle
Abrupt discontinuation of buprenorphine/naloxone is unacceptable medical care and carries significant morbidity and mortality risks. 1 Sudden cessation is no more appropriate with opioids than with antihypertensives or antihyperglycemics, and clinicians are obligated to offer a safe tapering regimen rather than abruptly stopping treatment. 1
Evidence-Based Tapering Approach
Taper Duration and Rate
For patients on Suboxone for ≥1 year, tapers should occur over several months to years, with 10% per month or slower being better tolerated than rapid tapers. 1
Each dose reduction should be 10% of the previous dose (not 10% of the starting dose), meaning if starting at 16mg, the first reduction goes to 14.4mg, then 13mg, etc. 1
The taper rate is determined entirely by the patient's ability to tolerate it—clinically significant withdrawal symptoms signal the need to slow or pause the taper. 1
Practical Taper Management
Begin with very small dose decreases initially (even smaller than 10%) to address patient anxiety and build confidence in the process. 1
Tapers may need to be paused and restarted when the patient is ready, and often must be slowed as patients reach lower dosages. 1
The target dose may not be zero—some patients benefit from maintenance at lower doses rather than complete discontinuation. 1
Once the smallest available dose is reached, extend the interval between doses (e.g., every other day, then every third day) before complete cessation. 1
Managing Withdrawal Symptoms
Use adjuvant treatments for withdrawal symptoms including clonidine, and counsel patients that withdrawal symptoms can be safely managed if they occur. 1
Maximize non-opioid treatments and address behavioral distress for patients struggling to tolerate the taper. 1
Monitor for and screen for anxiety, depression, and signs of opioid misuse that may be revealed during tapering. 1
Psychosocial Support Requirements
Patients undergoing Suboxone reduction should receive behavioral therapies to reduce withdrawal-related anxiety and increase treatment retention. 1
Cognitive behavioral therapy has been shown to improve outcomes among patients being treated with buprenorphine/naloxone and significantly reduces dropout rates and opioid use during treatment. 1
Consider meditation, yoga, and aerobic exercise as adjuncts that may attenuate discomfort related to opioid reduction. 1
Critical Risks of Discontinuation
Discontinuation of long-term buprenorphine therapy has been associated with mental health crisis, overdose events, overdose death, and increased risk for suicide. 1
Patients face dramatically increased overdose risk if they return to opioid use after stopping Suboxone due to loss of tolerance—provide naloxone and overdose education before any taper. 1
Death rates for overdose or suicide increase immediately after stopping opioids, with risk persisting for 3-12 months to 2 years. 1
Abrupt discontinuation in patients with opioid use disorder precipitates withdrawal and substantially increases relapse risk. 2, 3
Common Pitfalls to Avoid
Never perform "cold referrals" to clinicians who have not agreed to accept the patient—this constitutes patient abandonment. 1
Do not use straight-line percentage reductions from the starting dose, as this creates inappropriately large decreases at lower doses. 1
Avoid reversing a taper without carefully assessing and discussing with the patient the benefits and risks of increasing the opioid dosage. 1
Recognize that some patients who serially stop and start treatment may be managing dependency through sequential use of Suboxone and heroin to avoid withdrawal. 4
Special Considerations
For pregnant patients, access appropriate expertise before tapering due to possible risks to both the patient and fetus if withdrawal occurs. 1
Research shows no advantage to prolonging taper duration—a 7-day taper had better outcomes at taper completion than a 28-day taper, though long-term outcomes were equivalent. 5
Close observation and clinician availability to treat symptoms and manage fears are critical throughout the tapering process. 1