What is a suitable weekly taper plan for an adult patient with a history of opioid use disorder, currently taking Suboxone (buprenorphine/naloxone) 4/2mg twice daily (BID)?

Weekly Suboxone Taper Plan for Patient on 4/2mg BID

Critical Recommendation: Reconsider the Decision to Taper

Buprenorphine should typically be continued indefinitely rather than tapered, as maintenance therapy saves lives and prevents relapse—tapering should only be considered if there is a compelling medical reason to discontinue. 1

The evidence strongly favors maintenance over tapering:

• In a randomized trial comparing taper versus maintenance, patients who tapered had significantly worse outcomes: only 11% completed the trial versus 66% in maintenance, fewer maximum consecutive weeks of abstinence (2.7 vs 5.2 weeks), and 16 patients required reinitiation of buprenorphine after relapse. 2
• Tapering is less efficacious than ongoing maintenance treatment in patients receiving buprenorphine therapy in primary care. 2

If Taper Must Proceed: Recommended Protocol

Pre-Taper Requirements

Before initiating any taper, screen for depression, anxiety, insomnia, and active opioid use disorder—patients with active OUD are unlikely to tolerate abstinence and face dramatically increased overdose risk. 1

• Establish a collaborative taper agreement including commitment to treatment, patient non-abandonment, and clear communication about difficulties. 1
• Provide naloxone kits immediately when starting a taper, as patients face dramatically increased overdose risk if they return to illicit opioids after losing tolerance. 1
• Check the Prescription Drug Monitoring Program (PDMP) to identify all controlled substances the patient is receiving. 3

Taper Schedule: 10% Monthly Reduction (Minimum)

For patients stable on buprenorphine, taper extremely slowly at 10% per month or slower, using divided doses throughout the day. 1

Starting dose: 8mg total daily (4mg BID)

• Month 1: Reduce to 7.2mg daily (10% reduction) - can split as 3.6mg BID 1
• Month 2: Reduce to 6.5mg daily (10% of current dose) - can split as 3.25mg BID 1
• Month 3: Reduce to 5.8mg daily (10% of current dose) - can split as 2.9mg BID 1
• Month 4: Reduce to 5.2mg daily (10% of current dose) - can split as 2.6mg BID 1
• Month 5: Reduce to 4.7mg daily (10% of current dose) - can split as 2.35mg BID 1
• Month 6: Reduce to 4.2mg daily (10% of current dose) - can split as 2.1mg BID 1

Continue this pattern of 10% monthly reductions of the current dose (not the original dose) until reaching the lowest possible dose. 1

For patients on buprenorphine >1 year, even slower tapers (10% every 2 months) may be better tolerated. 1

Dosing Strategy During Taper

Divide the daily dose into 3-4 administrations rather than once-daily or twice-daily dosing to maintain more stable blood levels and reduce withdrawal symptoms. 1

Symptomatic Management (Aggressive and Liberal)

Use adjunctive medications liberally throughout the taper: 1

• For autonomic symptoms (sweating, tachycardia, hypertension, anxiety): Clonidine 0.1-0.2mg every 6-8 hours, lofexidine, or tizanidine as needed 1
• For insomnia and anxiety: Trazodone 50-100mg at bedtime, gabapentin 300-600mg three times daily, or mirtazapine 15-30mg at bedtime 1
• For gastrointestinal symptoms: Loperamide 2-4mg as needed for diarrhea, promethazine or ondansetron for nausea 1

Monitoring Requirements

Follow up at least monthly face-to-face during active tapering, with more frequent contact during difficult phases. 1

• Use the Clinical Opiate Withdrawal Scale (COWS) at every visit to monitor withdrawal severity objectively. 1
• Utilize team members (nurses, pharmacists, behavioral health professionals) for telephone or telehealth contact between visits. 1
• Monitor for protracted withdrawal syndrome: dysphoria, irritability, insomnia, anhedonia, vague sense of being unwell, and increased pain sensitivity that can persist months after completing the taper. 1

Managing Taper Difficulties

If clinically significant withdrawal symptoms emerge, pause the taper entirely and restart when the patient is ready. 1

• Slow the taper rate further—some patients may need reductions every 2 months rather than monthly. 1
• The taper will likely take 6-12 months minimum, possibly longer—the goal is durability of the taper, not speed. 1
• Tapers may be considered successful as long as the patient is making progress. 1

Critical Pitfall to Avoid

Never taper too quickly—research shows that rapid tapers (7-day vs 28-day) showed no advantage, with only 44% vs 30% providing opioid-free urine at end of taper, and no difference at 3-month follow-up (12% vs 13%). 4

Abrupt discontinuation can cause severe withdrawal and has been associated with new-onset psychotic symptoms in case reports. 5

If Taper Fails and Patient Relapses

The patient MUST be in mild-to-moderate opioid withdrawal (COWS >8) before restarting buprenorphine to avoid precipitated withdrawal. 1

• Wait at least 12 hours after short-acting opioids, 24 hours after extended-release formulations, or 72 hours after methadone. 1
• Start with 4-8mg sublingual based on withdrawal severity. 1
• Maintain the therapeutic relationship and do not abandon the patient—consider returning to maintenance therapy. 1

Alternative Approach: Extended-Release Injection

For patients who have previously been unable to taper fully off sublingual buprenorphine, a single dose of 100mg extended-release buprenorphine injection may facilitate discontinuation by mitigating prolonged withdrawal symptoms. 6