How can a patient safely withdraw from Brixadi (buprenorphine)?

Withdrawing from Brixadi (Buprenorphine)

Yes, patients can safely withdraw from Brixadi, but abrupt discontinuation must be avoided—gradual tapering over weeks to months is essential to prevent withdrawal symptoms and maintain patient safety. 1

Understanding Brixadi Withdrawal Risk

Brixadi is a long-acting injectable buprenorphine formulation with extended pharmacokinetics, making withdrawal management distinct from daily sublingual formulations 2. Physical dependence develops with regular buprenorphine use, and abrupt discontinuation will trigger opioid withdrawal syndrome characterized by restlessness, lacrimation, rhinorrhea, perspiration, chills, myalgia, mydriasis, irritability, anxiety, insomnia, nausea, vomiting, diarrhea, and elevated vital signs 1.

Tapering Approach

Initial Considerations

• Never abruptly discontinue Brixadi—this constitutes unacceptable medical care and violates the principle of patient non-abandonment 3
• Assess for opioid use disorder (OUD) before initiating taper, as patients with OUD are unlikely to tolerate abstinence and face heightened overdose risk 3
• Screen for depression, anxiety, and insomnia before and during the taper, as these symptoms commonly emerge or intensify during withdrawal 3

Recommended Taper Strategy

Begin with very small dose reductions (5-10% of current dose) and adjust based on patient tolerance 3:

• Initial reductions of 5-10% help address patient anxiety and build confidence in the process 3
• Each new dose should be 90% of the previous dose (not a straight-line reduction from starting dose) 3
• Taper rate is determined entirely by the patient's ability to tolerate it 3
• Slow tapers may require several months to years, particularly for patients on long-term therapy 3
• The target dose may not be zero—some patients benefit from maintenance at lower doses rather than complete elimination 3

Withdrawal Symptom Management

Proactively treat withdrawal symptoms with adjuvant medications and provide intensive clinical support 3:

• Use clonidine for autonomic symptoms (sweating, tachycardia, hypertension) 3
• Address pain separately, recognizing that pain itself may be a withdrawal symptom rather than exacerbation of original chronic pain 3
• Treat anxiety and depressive symptoms aggressively as they predict taper discontinuation 3
• Provide adequate clinician time and support throughout the process 3

Protracted Withdrawal Syndrome

Expect protracted withdrawal symptoms lasting months after buprenorphine elimination 3:

• Symptoms include dysphoria, irritability, insomnia, anhedonia, and vague sense of being unwell 3
• These must be discussed with patients beforehand and either preempted or treated 3
• Cannot be easily differentiated from chronic pain symptoms in patients not previously treated with opioids 3

Alternative Strategies

Transition to Sublingual Buprenorphine

• Consider transitioning from Brixadi to daily sublingual buprenorphine/naloxone for more granular dose control during tapering 3
• This allows for smaller, more frequent dose adjustments based on patient response 3

Continuation at Lower Dose

• If taper fails or causes intolerable symptoms, resumption at a lower maintenance dose is appropriate 3
• This is preferable to complete discontinuation with subsequent relapse or use of illicit opioids 3

Critical Safety Principles

• Establish a collaborative treatment plan with clear communication about goals, expectations, and contingency plans 3
• Ensure patient understands this is not abandonment or giving up on pain management 3
• Monitor closely with frequent follow-up during taper 3
• Have naloxone available and educate patient on overdose prevention, as risk increases if patient seeks illicit opioids 3
• Never perform "cold referrals" to clinicians who haven't agreed to accept the patient—this constitutes abandonment 3

Common Pitfalls to Avoid

• Fear of withdrawal is a primary reason patients continue opioid therapy and drop out of tapering programs 3
• Inadequately addressed withdrawal symptoms trigger taper dropouts and early opioid resumption 3
• Patients' fear that pain will become intolerable must be taken seriously and addressed directly 3
• Failing to recognize that increased pain during withdrawal may be a withdrawal symptom rather than disease progression 3