What is the recommended taper schedule for an adult patient with a history of opioid use disorder taking Suboxone (buprenorphine) 10 mg twice daily (BID)?

Buprenorphine Taper from 10 mg BID

For a patient on Suboxone 10 mg BID (20 mg total daily) seeking to discontinue, I strongly recommend against tapering off buprenorphine in most cases, as the majority of patients who taper will relapse and return to treatment—maintenance therapy is the evidence-based standard of care for opioid use disorder. 1, 2

Critical Context: Maintenance vs. Discontinuation

• Buprenorphine should not be reduced or discontinued in an attempt to comply with analgesia guidelines when used as medication-assisted treatment (MAT) for opioid use disorder 1
• Research shows that among patients who successfully tapered off buprenorphine, an estimated 61% returned to buprenorphine treatment within 2 years, and many patients tapered unsupervised 2
• Long-term maintenance with buprenorphine is the recommended treatment approach that saves lives and demonstrates effectiveness 1
• Patient agreement and interest in tapering is essential for any chance of success 1

If Taper is Pursued Despite Recommendations

Tapering Protocol

For patients on buprenorphine for ≥1 year (which is likely at this dose), reduce by 10% of the current dose per month, not the original dose 1:

• Month 1: Reduce from 20 mg/day to 18 mg/day (10% reduction)
• Month 2: Reduce to 16.2 mg/day (10% of 18 mg)
• Month 3: Reduce to 14.6 mg/day (10% of 16.2 mg)
• Continue this pattern, always calculating 10% of the current dose 1

The taper will likely require a minimum of 6-12 months, and possibly much longer—the goal is durability, not speed 1.

Key Monitoring Requirements

• Follow up at least monthly during the taper, with more frequent contact during difficult phases 1
• Monitor for withdrawal symptoms including anxiety, insomnia, diaphoresis, tremor, myalgia, diarrhea, mydriasis, and piloerection 1
• Screen for depression, anxiety, and return to illicit opioid use at every visit 1
• Clinically significant withdrawal symptoms signal the need to further slow the taper rate or pause entirely 1

Essential Adjunctive Measures

• Maximize non-opioid pain treatments and behavioral therapies throughout the taper 1
• Strongly consider offering overdose prevention education and take-home naloxone, as patients lose tolerance and face increased overdose risk if they return to previous doses or use illicit opioids 1
• Integrate cognitive behavioral therapy (CBT) or other evidence-based psychological therapies, which significantly increase success rates 1
• Team members including nurses, pharmacists, and behavioral health professionals should provide ongoing support 1

Critical Pitfalls to Avoid

• Never taper abruptly or too quickly—slow tapering reduces severity of withdrawal symptoms 1
• Never abandon the patient even if tapering is unsuccessful; maintain the therapeutic relationship and consider returning to maintenance therapy 1
• Do not reduce by a percentage of the original dose; always calculate reductions based on the current dose to prevent disproportionately large final reductions 1
• Pauses in the taper are acceptable and often necessary when withdrawal symptoms emerge 1
• Once the smallest available dose is reached, the interval between doses can be extended before complete discontinuation 1

Evidence on Taper Duration

• Research comparing 7-day versus 28-day tapers after stabilization showed no advantage to prolonging the taper duration—44% of the 7-day group versus 30% of the 28-day group provided opioid-free urine at end of taper, but both groups had identical poor outcomes (18% and 13% opioid-free) at 1-month and 3-month follow-up 3
• However, this study examined short tapers after brief stabilization, not the slow tapers recommended for long-term maintenance patients 3

When to Refer to Specialist

• Patients with unstable psychiatric comorbidities require specialist involvement 1
• Patients with co-occurring substance use disorders should be referred 1
• Previous unsuccessful taper attempts warrant specialist consultation 1

Special Consideration: Concurrent Benzodiazepine Use

If the patient is also taking benzodiazepines, the benzodiazepine must be tapered first due to higher withdrawal risks (including seizures and death), while keeping the buprenorphine dose stable 4.