What is the recommended taper schedule for a adult patient with a history of opioid use disorder and currently taking 12 mg of Suboxone (buprenorphine/naloxone)?

Buprenorphine Taper from 12mg: Recommendation

For a patient currently on 12mg Suboxone, reduce the dose by 10% per month (1.2mg decrements), divide the daily dose into 3-4 administrations throughout the day rather than once-daily dosing, provide aggressive symptomatic management with clonidine and other adjunctive medications, and maintain monthly face-to-face follow-up visits. 1

Critical Consideration Before Proceeding

Medication-assisted treatment with buprenorphine should typically be continued indefinitely rather than tapered, as this approach saves lives and prevents relapse. 1 Tapering should only be considered if there is a compelling medical reason to discontinue buprenorphine. 1 The highest quality evidence shows that tapering is significantly less efficacious than ongoing maintenance treatment—patients who tapered had only 35% opioid-negative urine samples compared to 53% in those who continued maintenance, and only 11% of taper patients completed treatment versus 66% of maintenance patients. 2

If Taper is Still Pursued: Specific Protocol

Month-by-Month Dosing Schedule

• Month 1: Reduce from 12mg to 10.8mg daily (10% reduction) 3, 1
• Month 2: Reduce from 10.8mg to 9.7mg daily 3, 1
• Month 3: Reduce from 9.7mg to 8.7mg daily 3, 1
• Continue this pattern of 10% monthly reductions from the original 12mg dose 3, 1

For patients on buprenorphine longer than 1 year, even slower tapers of 10% every 2 months may be better tolerated. 1

Dosing Strategy to Minimize Withdrawal

Divide the daily dose into 3-4 administrations throughout the day rather than once-daily dosing to maintain more stable blood levels and reduce withdrawal symptoms. 1 For example, at 12mg daily, take 3mg four times daily or 4mg three times daily rather than 12mg once daily.

Aggressive Symptomatic Management Protocol

Autonomic Symptoms (sweating, tachycardia, hypertension, anxiety)

• Clonidine 0.1-0.2mg every 6-8 hours as needed 1
• Alternatively, lofexidine or tizanidine 1

Sleep and Anxiety

• Trazodone 50-100mg at bedtime 1
• Gabapentin 300-600mg three times daily 1
• Alternatively, mirtazapine 15-30mg at bedtime 1

Gastrointestinal Symptoms

• Loperamide 2-4mg as needed for diarrhea 1
• Ondansetron or promethazine for nausea 1

Use the Clinical Opiate Withdrawal Scale (COWS) at every visit to objectively monitor withdrawal severity—if COWS scores indicate clinically significant withdrawal, this signals the need to slow the taper rate further. 1

Mandatory Follow-Up Requirements

• Monthly face-to-face visits minimum during active tapering 1
• Utilize team members (nurses, pharmacists, behavioral health professionals) for telephone or telehealth contact between visits 1
• At each visit, document any relapses, reemergence of cravings or withdrawal, perform random urine drug testing, conduct pill or wrapper counts, and check state prescription drug monitoring program records 4

Critical Safety Measures

Provide naloxone kits immediately when starting the taper, as patients face dramatically increased overdose risk if they return to illicit opioids after losing tolerance. 1 This is non-negotiable—the risk of fatal overdose increases substantially once tolerance is lost. 1

Screen for depression, anxiety, and opioid use disorder before and during the taper, as active mental health conditions predict taper failure. 1

Managing Taper Difficulties

If Withdrawal Symptoms Become Intolerable

• Pause the taper entirely and restart when the patient is ready 3, 1
• Slow the taper rate further—some patients may need reductions every 2 months rather than monthly 1
• Maximize nonopioid pain treatments and address behavioral distress 3
• Before reversing a taper and increasing the dose back up, carefully assess and discuss with the patient the benefits and risks 3

As Doses Get Lower

Tapers often need to be slowed as patients reach low dosages. 3, 1 Once the smallest available dose is reached (typically 2mg), extend the interval between doses rather than continuing to reduce the dose—eventually opioids can be stopped when taken less frequently than once a day. 3

Protracted Withdrawal Syndrome Warning

Patients may experience dysphoria, irritability, insomnia, anhedonia, a vague sense of being unwell, and increased pain sensitivity for months after completing the taper. 1 This protracted withdrawal syndrome is distinct from acute withdrawal and requires ongoing support.

Alternative Approach: Extended-Release Buprenorphine

For patients who have repeatedly failed traditional tapers due to intolerable withdrawal symptoms, a single 100mg injection of extended-release buprenorphine after tapering to low-dose sublingual buprenorphine (2-4mg) can facilitate final discontinuation by mitigating prolonged withdrawal symptoms. 5 This novel approach has shown success in case series when traditional tapers failed. 5

If Patient Returns to Opioid Use

The patient MUST be in mild-to-moderate opioid withdrawal (COWS >8) before restarting buprenorphine to avoid precipitated withdrawal. 1, 6 Wait at least 12 hours after short-acting opioids, 24 hours after extended-release formulations, or 72 hours after methadone before restarting. 1, 6 Start with 4-8mg sublingual based on withdrawal severity. 6

Common Pitfalls to Avoid

• Tapering too rapidly: The 2022 CDC guidelines explicitly state that tapers of 10% per month or slower are better tolerated than more rapid tapers for patients on long-term therapy. 3
• Once-daily dosing during taper: This creates peaks and troughs that worsen withdrawal symptoms—divided dosing is essential. 1
• Inadequate symptomatic management: Withdrawal symptoms are the primary reason tapers fail—aggressive use of adjunctive medications is critical. 1
• Insufficient follow-up: Monthly visits are the minimum—more frequent contact through team members improves success rates. 1
• Failing to provide naloxone: This is a life-threatening omission given the dramatically increased overdose risk. 1