What are the guidelines for safely discontinuing Suboxone (buprenorphine) in a patient with a history of opioid use disorder, including recommended comfort medications and dosages?

Patient Guide to Suboxone: Starting Doses, Side Effects, and Comfort Medications

What is Suboxone and Why It Works

Suboxone (buprenorphine/naloxone) is the preferred first-line medication for treating opioid use disorder, combining a partial opioid agonist with an abuse-deterrent component that prevents misuse while safely managing withdrawal symptoms. 1, 2

• Buprenorphine is a partial agonist at mu opioid receptors, meaning it activates these receptors but with a ceiling effect that limits respiratory depression and makes overdose less likely 3, 4
• The naloxone component is poorly absorbed when taken sublingually (under the tongue) as prescribed, but prevents misuse by causing severe withdrawal if the medication is crushed and injected 3, 5
• This combination product (Suboxone) is preferred over buprenorphine alone specifically because of this safety feature 3

When to Start Suboxone: Critical Timing

You must be in active opioid withdrawal before taking your first dose of Suboxone, or you will experience precipitated withdrawal—a severe and sudden worsening of symptoms. 1, 2

• Your provider will use the Clinical Opiate Withdrawal Scale (COWS) to assess your symptoms, and you need a score greater than 8 before starting 2
• Active withdrawal symptoms include: muscle aches, sweating, dilated pupils, runny nose, goosebumps, nausea, diarrhea, anxiety, and restlessness 2
• Special warning for methadone users: If you've been taking methadone, you face higher risk of severe and prolonged precipitated withdrawal when switching to Suboxone—you may need to wait 24-72 hours after your last methadone dose and have more severe withdrawal symptoms before starting 2

Starting Doses

The initial dose is 4-8 mg of buprenorphine taken sublingally, with the maximum first-day total dose not exceeding 16 mg. 1, 2

• Your provider will give you the initial dose based on your withdrawal severity 2
• After 30-60 minutes, you'll be reassessed, and additional doses may be given if withdrawal symptoms persist 2
• The goal is reducing symptoms to a manageable level, not complete elimination 1
• Most patients stabilize on maintenance doses around 16 mg daily, though the effective range is 7-24 mg per day 6, 7

Common Side Effects

Expect these side effects, which are generally mild and improve over time: 6

• Constipation (most common opioid-related effect) 7
• Headache 6
• Nausea 6
• Drowsiness and sedation 6
• Dizziness 6
• Anxiety 6
• Sweating 7

Approximately 50% of patients report adverse events in the first 4 weeks, dropping to 26.6% by four months, with very few discontinuing treatment due to side effects. 5

Comfort Medications During Withdrawal

Clonidine for Autonomic Symptoms

Clonidine is recommended to reduce autonomic hyperactivity symptoms like sweating, rapid heart rate, and high blood pressure during opioid withdrawal. 1

• Clonidine should be withheld if your systolic blood pressure is below 90 mmHg or diastolic blood pressure is below 60 mmHg 1
• It helps with symptoms like anxiety, restlessness, muscle aches, and sweating 1
• Your blood pressure will be monitored before each dose 1

When Buprenorphine Alone Isn't Enough

Additional comfort medications are titrated to your specific symptoms with no predetermined dose ceiling—every dose adjustment is based on documented withdrawal severity using validated assessment tools. 1, 8

• Your provider will reassess you 30-60 minutes after each medication adjustment 1, 2
• Medications are given to prevent symptoms before they become severe, not just to react to severe symptoms 1
• The taper rate and medication doses are determined by your ability to tolerate them, not by arbitrary schedules 1, 8

Choosing Between Suboxone and Other Treatments

Suboxone is preferred over methadone for most patients because it can be prescribed in office-based practices and has a better safety profile, while methadone requires daily visits to federally regulated treatment programs. 3

• Buprenorphine is as effective as methadone for treatment retention and decreased opioid use when prescribed at fixed dosages of at least 7 mg per day 6
• Dosages of 16 mg per day are clearly superior to placebo 6
• However, if you're already stable on methadone maintenance, continuing methadone rather than switching to buprenorphine may be the better choice 2

What to Expect: Realistic Outcomes

Brief treatment periods with rapid medication tapers are associated with high rates of relapse; therefore, longer-term or maintenance treatment is generally indicated for opioid dependence. 3

• Sporadic opioid use is not uncommon in the first few months of treatment and should be addressed by increased visit frequency and more intensive behavioral therapy engagement 6
• Small reductions in drug use have important health benefits—you don't need to achieve perfect abstinence immediately 3
• The combination of Suboxone with cognitive behavioral therapy and supportive counseling significantly improves treatment outcomes compared to medication alone 1, 8

Ongoing Monitoring and Follow-Up

Your follow-up visits will include documentation of any relapses, reemergence of cravings or withdrawal, random urine drug testing, pill or wrapper counts, and checks of state prescription drug database records. 6

• You'll be assessed using validated tools like COWS continuously to monitor withdrawal symptoms: scores 5-12 = mild, 13-24 = moderate, 25-36 = moderately severe, >36 = severe 1
• Your respiratory rate, pulse, blood pressure, and signs of distress will be monitored regularly 1
• A follow-up appointment should be arranged within 3-7 days after starting treatment 2

Discharge Planning and Safety

When you leave the hospital or clinic, you'll receive a prescription for buprenorphine/naloxone 16 mg sublingual daily for 3-7 days or until your follow-up appointment, along with overdose prevention education and a take-home naloxone kit. 2

• A typical discharge prescription is: buprenorphine/naloxone 8 mg/2 mg sublingual tablet or film, take 2 tablets/films once daily in the morning, dispense 6, no refills 2
• You'll also be offered hepatitis C and HIV screening and reproductive health counseling 2
• Resources for community support and counseling services will be provided 2

Critical Warnings

Never take Suboxone before you're in active withdrawal—this can precipitate severe withdrawal symptoms due to buprenorphine's high binding affinity and partial agonist properties. 2

• Patients injecting Suboxone report it's like injecting "nothing" with no euphoria or that it's a bad experience, confirming the abuse-deterrent properties 5
• Individualized approaches are necessary if you're pregnant, on chronic opioid therapy for pain, anticipating surgery, have liver disease, or respiratory failure 2
• Suboxone can interact with medications that prolong the QT interval (heart rhythm), cause serotonin syndrome, or cause severe constipation 3

Long-Term Success

Medication-assisted treatment with buprenorphine should be viewed as long-term maintenance therapy, not a short-term detox, with the goal of sustained recovery and improved quality of life. 3, 6

• Patient characteristics associated with successful buprenorphine maintenance include stable or controlled medical or psychiatric comorbidities and a safe, substance-free environment 6
• Psychosocial treatments must be offered alongside medications—the combination significantly improves outcomes 1
• Lack of psychosocial treatment availability should never delay starting pharmacotherapy 1