What is a recommended taper plan for an adult patient with a history of opioid use disorder and no significant comorbidities, currently taking Suboxone (buprenorphine) 4mg twice daily (BID)?

Suboxone Taper Plan for Patient on 4mg BID

For a patient on Suboxone 4mg BID (8mg total daily), begin with 10% monthly dose reductions (0.8mg decrements), but you must first strongly counsel the patient that maintenance therapy is significantly superior to tapering—buprenorphine maintenance reduces overdose death by up to threefold compared to tapering, which has high failure rates. 1, 2

Critical Pre-Taper Counseling

Before initiating any taper, you must have a frank discussion about the evidence:

• Maintenance therapy is the gold standard: A randomized trial showed patients who tapered had only 35% opioid-negative urine samples versus 53% in maintenance patients, with only 11% completing the taper versus 66% completing maintenance treatment 3
• Most patients return to buprenorphine: Real-world data shows an estimated 61% of patients who successfully taper off return to buprenorphine treatment within 2 years 4
• Overdose risk increases dramatically: Patients lose tolerance during tapering and face substantially higher overdose risk if they return to illicit opioids 2

If Patient Still Desires Taper After Counseling

Pre-Taper Requirements

• Assess for current opioid use disorder using DSM-5 criteria—if active disorder is present, tapering is contraindicated 1
• Proactively treat depression, anxiety, and insomnia, as these predict taper failure 1
• Establish a written collaborative agreement documenting patient responsibilities and your commitments 1
• Document baseline pain levels and functional status to objectively track changes 1
• Provide naloxone kit immediately before starting taper due to increased overdose risk 2

Recommended Taper Protocol

Month 1: Reduce from 8mg daily to 7.2mg daily (0.8mg reduction = 10% of starting dose)

• Divide into 3-4 doses throughout the day rather than BID dosing to maintain stable blood levels and reduce withdrawal symptoms 2
• Example: 2.4mg three times daily or 1.8mg four times daily

Month 2: Reduce to 6.5mg daily (10% reduction from Month 1 dose, not from original dose—this is hyperbolic tapering) 1

Month 3: Reduce to 5.8mg daily (continuing 10% monthly reductions of the current dose) 1

Continue this pattern: Each new dose should be 90% of the previous dose, not a linear reduction from the starting dose 1

Critical Modification for Long-Term Users

• If the patient has been on buprenorphine ≥1 year, slow the taper to 5-10% monthly reductions instead of 10% 1, 2
• Some patients may need reductions every 2 months rather than monthly 2
• The goal is durability of taper, not rapidity 1

Aggressive Symptomatic Management

Use adjunctive medications liberally at every visit 2:

For Autonomic Symptoms (sweating, tachycardia, hypertension, anxiety):

• Clonidine 0.1-0.2mg every 6-8 hours (start low due to hypotension risk) 5, 2
• Lofexidine (FDA-approved for opioid withdrawal) 5, 2
• Tizanidine if clonidine causes excessive hypotension 5

For Insomnia and Anxiety:

• Trazodone 50-100mg at bedtime 5
• Gabapentin 300-600mg three times daily 5
• Mirtazapine 15-30mg at bedtime 5

For Gastrointestinal Symptoms:

• Loperamide 2-4mg as needed for diarrhea (warn about abuse potential in high doses) 5
• Antiemetics (promethazine or ondansetron) for nausea 5

Monitoring Protocol

• Monthly face-to-face visits minimum during active tapering 2
• Use the Clinical Opiate Withdrawal Scale (COWS) at every visit to objectively monitor withdrawal severity 2
• Utilize team members (nurses, pharmacists, behavioral health professionals) for telephone or telehealth contact between visits 2
• Monitor for return of psychiatric symptoms and suicidal ideation 1
• Obtain urine drug screens at each visit to detect illicit opioid use 3

Protracted Withdrawal Syndrome

Counsel the patient that months after completing the taper, they may experience 1:

• Dysphoria and irritability
• Insomnia and anhedonia
• Vague sense of being unwell
• Increased pain sensitivity

These symptoms are expected, cannot be easily differentiated from underlying chronic pain, and may persist for months 5, 1

Managing Taper Difficulties

If the patient experiences intolerable withdrawal symptoms or returns to opioid use:

• Pause the taper entirely and maintain the current dose until the patient is ready to proceed 2
• Slow the taper rate further—consider reductions every 2 months instead of monthly 2
• Increase adjunctive medication doses 2
• Do not view this as failure—reinitiate maintenance therapy if needed 1

Restarting Buprenorphine After Failed Taper

If the patient returns to illicit opioid use and needs to restart buprenorphine:

• The patient MUST be in mild-to-moderate opioid withdrawal (COWS >8) before restarting to avoid precipitated withdrawal 2
• Wait at least 12 hours after short-acting opioids (heroin, oxycodone IR) 2
• Wait at least 24 hours after extended-release formulations 2
• Wait at least 72 hours after methadone 2
• Start with 4-8mg sublingual based on withdrawal severity, reassess after 30-60 minutes 5

Your Legal and Ethical Obligations

You are obligated to either 1:

1. Offer a comfortable, safe tapering regimen with close monitoring, OR
2. Obtain agreement from another physician to accept care, OR
3. Continue maintenance therapy if taper fails

"Cold referrals" to clinicians who have not agreed to accept the patient constitute abandonment 1

Alternative: Extended-Release Buprenorphine for Tapering

Emerging evidence suggests a single 100mg extended-release subcutaneous buprenorphine injection may provide a more tolerable taper for patients on 2-6mg daily sublingual buprenorphine, with buprenorphine elimination occurring over 24 weeks 6. However, this approach requires the patient to first taper sublingual buprenorphine to 2-6mg daily before injection, and 3 of 8 patients in one case series experienced mild adverse effects 6.