What is the recommended tapering schedule for a patient with opioid use disorder stabilized on Suboxone (buprenorphine/naloxone)?

Buprenorphine Tapering for Opioid Use Disorder

For patients stabilized on Suboxone (buprenorphine/naloxone), long-term maintenance therapy is strongly preferred over tapering, as maintenance saves lives and prevents relapse—but if tapering is pursued, reduce by 10% of the current dose per month (not the original dose) over a minimum of 6-12 months, with monthly monitoring and aggressive symptomatic management. 1, 2

Critical Framework: Maintenance vs. Tapering

• Buprenorphine maintenance is the gold standard for opioid use disorder and should typically be continued indefinitely rather than tapered, as this approach demonstrates superior outcomes for preventing relapse and overdose death 1, 2
• Research directly comparing taper versus maintenance in primary care showed that patients in the taper group had only 35% opioid-negative urine samples compared to 53% in the maintenance group, with significantly more days of illicit opioid use (1.27 vs 0.47 days per week) and lower treatment completion (11% vs 66%) 3
• Patient agreement and genuine interest in tapering is essential for any chance of success—forced or coerced tapering dramatically increases relapse and overdose risk 1, 2

When Tapering is Considered

Only pursue tapering if:

• The patient has a compelling medical reason to discontinue buprenorphine 2
• The patient demonstrates sustained stability with no illicit opioid use, stable psychiatric status, and strong psychosocial support 1
• The patient fully understands and accepts the dramatically increased overdose risk if they return to illicit opioids after losing tolerance 1, 2

Recommended Tapering Protocol

Taper Schedule

• For patients on buprenorphine ≥1 year: reduce by 10% of the current dose per month (e.g., from 8mg to 7.2mg in month 1, then to 6.5mg in month 2, calculating each reduction from the current dose, not the original) 1, 2
• For a patient stable on 8mg Suboxone, the first reduction would be 0.8mg (10% of 8mg), bringing the dose to 7.2mg 2
• The taper will require a minimum of 6-12 months, and possibly much longer—the goal is durability of the taper, not speed 1, 2
• Some patients may need even slower tapers (10% every 2 months) for better tolerance 2

Dosing Strategy During Taper

• 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 2
• This divided dosing approach helps minimize peak-trough fluctuations that can trigger withdrawal symptoms 2

Aggressive Symptomatic Management

Use adjunctive medications liberally throughout the taper: 2

Autonomic Symptoms (sweating, tachycardia, hypertension, anxiety)

• Clonidine 0.1-0.2mg every 6-8 hours as needed 2
• Lofexidine (FDA-approved specifically for opioid withdrawal) 4
• Tizanidine as an alternative 2

Insomnia and Anxiety

• Trazodone 50-100mg at bedtime 2
• Gabapentin 300-600mg three times daily 2
• Mirtazapine 15-30mg at bedtime 2

Gastrointestinal Symptoms

• Loperamide 2-4mg as needed for diarrhea 2
• Antiemetics such as promethazine or ondansetron for nausea 2

Monitoring Requirements

• Follow up at least monthly during the taper (face-to-face visits minimum), with more frequent contact during difficult phases 1, 2
• Use the Clinical Opiate Withdrawal Scale (COWS) at every visit to objectively monitor withdrawal severity 2
• Screen for depression, anxiety, and return to illicit opioid use at every visit 1
• Monitor for withdrawal symptoms including anxiety, insomnia, diaphoresis, tremor, myalgia, diarrhea, mydriasis, and piloerection 1
• Utilize team members (nurses, pharmacists, behavioral health professionals) for telephone or telehealth contact between visits 2

Essential Adjunctive Measures

• Maximize non-opioid pain treatments and behavioral therapies throughout the taper 1
• Integrate cognitive behavioral therapy (CBT) or other evidence-based psychological therapies, which significantly increase success rates 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, 2
• Offer hepatitis C and HIV screening during the withdrawal process 2

Managing Taper Difficulties

If withdrawal symptoms emerge or the patient struggles: 1, 2

• Pause the taper entirely and hold at the current dose until the patient stabilizes 2
• Slow the taper rate further—some patients may need reductions every 2 months rather than monthly 2
• Never abandon the patient even if tapering is unsuccessful; maintain the therapeutic relationship and consider returning to maintenance therapy 1
• Clinically significant withdrawal symptoms signal the need to further slow the taper rate 1

Protracted Withdrawal Syndrome

• Patients may experience dysphoria, irritability, insomnia, anhedonia, a vague sense of being unwell, and increased pain sensitivity for months after completing the taper 2
• This protracted withdrawal requires ongoing support and symptomatic management even after buprenorphine is fully discontinued 2

Critical Pitfalls to Avoid

• Never taper abruptly or too quickly—slow tapering reduces severity of withdrawal symptoms 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
• Never abandon the patient even if tapering is unsuccessful; maintain the therapeutic relationship and consider returning to maintenance therapy 1
• Do not attempt to taper buprenorphine to comply with analgesia guidelines when used as medication-assisted treatment for opioid use disorder 1

Special Considerations

• Patients with unstable psychiatric comorbidities require specialist involvement 1
• Patients with co-occurring substance use disorders should be referred to addiction specialists 1
• 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 1

Restarting Buprenorphine After Failed Taper

If the patient relapses and needs to restart buprenorphine: 2

• The patient MUST be in mild-to-moderate opioid withdrawal (COWS >8) before restarting buprenorphine to avoid precipitated withdrawal 2
• Wait at least 12 hours after short-acting opioids, 24 hours after extended-release formulations, or 72 hours after methadone 2
• Start with 4-8mg sublingual based on withdrawal severity 2

Evidence Regarding Taper Duration

• Research comparing 7-day versus 28-day tapers after buprenorphine stabilization found that 44% of the 7-day taper group provided opioid-free urine specimens at the end of taper compared to only 30% of the 28-day group, but there were no differences at 1-month and 3-month follow-ups (both groups had only 18% and 12-13% opioid-free rates respectively), suggesting that rapid tapers offer no advantage and both approaches have poor long-term outcomes 5
• This evidence reinforces that maintenance therapy is superior to any taper approach for sustained opioid abstinence 5, 3