What is a suitable taper plan for an adult patient with opioid use disorder to discontinue methadone (opioid agonist) 280mg/day?

Methadone Taper Protocol for 280mg Daily Dose

For a patient on methadone 280mg/day for opioid use disorder, reduce the dose by approximately 10% of the current dose per week, which translates to an initial reduction of 28mg in week 1, bringing the dose to 252mg/day, then continuing with 10% weekly reductions of the remaining dose until complete discontinuation over approximately 6-9 months. 1

Critical Safety Considerations

• Never abruptly discontinue methadone at this high dose—deaths have occurred during rapid withdrawal from chronic, high-dose methadone treatment 2
• The FDA explicitly warns that "a high degree of opioid tolerance does not eliminate the possibility of methadone overdose" and that deaths have been reported during conversion from high-dose methadone 2
• Methadone has a long and variable elimination half-life (mean 22 hours, range 5-130 hours), with the active R-enantiomer averaging 40 hours, meaning tissue stores accumulate and withdrawal symptoms may be delayed 3
• Avoid converting to methadone for weaning purposes due to complex pharmacokinetics, nonlinear morphine equivalency, and documented high lethality 1

Recommended Tapering Schedule

Initial Phase (Weeks 1-4)

• Week 1: Reduce from 280mg to 252mg (10% reduction = 28mg decrease) 1
• Week 2: Reduce from 252mg to 227mg (10% of current dose = 25mg decrease) 1
• Week 3: Reduce from 227mg to 204mg (10% of current dose = 23mg decrease) 1
• Week 4: Reduce from 204mg to 184mg (10% of current dose = 20mg decrease) 1

Middle Phase (Continuing 10% Weekly Reductions)

• Continue reducing by 10% of the current dose (not the original dose) each week 1
• For patients on very high doses or with prolonged use, consider slowing to 10% per month once below 100mg 1
• The taper rate must be determined by the patient's ability to tolerate reductions, not by a rigid schedule—pauses are acceptable when withdrawal symptoms emerge 1

Final Phase (Below 30-40mg)

• Once the dose reaches approximately 30-40mg, consider slowing the taper further to 5-10mg reductions every 1-2 weeks 2, 4
• Research suggests that withdrawal at approximately 3% of initial dose per week (rather than 10%) results in better completion rates, though this would extend the taper to 18-24 months 4
• Total expected duration: 6-12 months minimum for a dose this high, potentially longer if the patient has been on methadone for many years 1

Managing Withdrawal Symptoms

Pharmacological Adjuvants

• Clonidine 0.1-0.3mg three times daily (or up to 16 mcg/kg/day) significantly reduces withdrawal symptoms including anxiety, restlessness, and autonomic symptoms, though it is less effective for insomnia and muscle aching 5
• Monitor for orthostatic hypotension with clonidine—start with small doses and titrate carefully 1, 5
• Tizanidine is an alternative α2-agonist that is less effective than clonidine but causes less hypotension 1
• Lofexidine is FDA-approved specifically for opioid withdrawal symptom control 1

Symptomatic Management

• For insomnia: Trazodone, mirtazapine, or tricyclic antidepressants for short-term use 1
• For anxiety/irritability: Gabapentin (start 100-300mg at bedtime, titrate by 100-300mg every 1-7 days as tolerated) 1
• For GI symptoms: Loperamide (but warn about abuse potential and cardiac risks at high doses) 1
• For muscle aches: NSAIDs or acetaminophen 1

Protracted Withdrawal Syndrome

• Expect dysphoria, irritability, insomnia, anhedonia, or vague malaise for months after complete discontinuation 1
• These symptoms must be anticipated, discussed with the patient beforehand, and treated supportively 1
• Cannot be easily differentiated from underlying chronic pain or mood disorders 1

Monitoring Requirements

• Follow up at least monthly during the taper, with more frequent contact (weekly or biweekly) during difficult phases 1
• At each visit, assess for:
  • Withdrawal symptoms (anxiety, restlessness, insomnia, muscle aches, GI distress, autonomic symptoms) 1
  • Depression and suicidal ideation 1
  • Illicit opioid use (urine drug screens) 6, 4
  • Blood pressure if using clonidine 5

Alternative Approach: Transition to Buprenorphine

When to Consider

• If the patient is experiencing intolerable withdrawal symptoms during methadone taper 7
• If there are urgent medical reasons to discontinue methadone (e.g., QTc prolongation) 7
• If the patient desires faster transition off full agonist therapy 1

Standard Buprenorphine Induction Protocol

• Taper methadone to 30-40mg/day first, as this dose prevents acute withdrawal in most patients and allows for easier buprenorphine induction 1
• Patient must be in mild opioid withdrawal (COWS score ≥8-12) before starting buprenorphine to avoid precipitated withdrawal 1
• Initiate buprenorphine 2-4mg, repeated at 2-hour intervals if tolerated, until withdrawal symptoms resolve (typically 4-8mg first day) 1
• Target maintenance dose of 16-24mg/day divided into 3-4 daily doses for analgesia (unlike OUD treatment where once-daily dosing is standard) 1

Rapid Transition Protocol (Inpatient Only)

• For urgent situations, naltrexone 25mg can precipitate withdrawal, followed 1 hour later by "rescue" with buprenorphine/naloxone 16mg/4mg 7
• This protocol successfully transitioned a patient from 95mg methadone within 2 hours, though COWS peaked at 21 before rapidly declining 7
• This approach requires inpatient monitoring with naloxone available and frequent assessment of consciousness and respiration 7

Common Pitfalls to Avoid

• Do not reduce by a fixed amount each week—always calculate 10% of the current dose, not the original dose, to prevent disproportionately large final reductions 1
• Do not abandon the patient if tapering is unsuccessful—maintain the therapeutic relationship and consider maintenance therapy 1
• Do not confuse withdrawal-induced pain with exacerbation of original chronic pain—pain itself is a withdrawal symptom due to increased firing of descending pain facilitatory tracts 1
• Do not ignore protracted withdrawal—symptoms persisting months after discontinuation are expected and require ongoing support 1
• Do not use methadone for weaning in outpatients due to complex pharmacokinetics and high mortality risk 1

Enhancing Success Rates

• Cognitive behavioral therapy (CBT) during the taper significantly increases completion rates 1
• Patient education about withdrawal symptoms, expected timeline, and the fact that many patients feel and function better after tapering improves engagement 1
• Interdisciplinary chronic pain rehabilitation programs that incorporate opioid tapering with psychosocial treatments and physical rehabilitation achieve successful tapers (often to zero) in 3-4 weeks with lower dropout rates than slow outpatient tapers, though this requires daily visits and voluntary participation 1
• Shared decision-making and patient agreement with the taper plan is essential for success 1

When to Refer to Specialist

• History of withdrawal seizures 1
• Unstable psychiatric comorbidities 1
• Co-occurring substance use disorders requiring medication-assisted treatment 1
• Previous unsuccessful office-based tapering attempts 1
• Need for rapid transition due to medical urgency (e.g., cardiac complications) 7