Should a patient with a history of opioid dependence, who has been stable on Suboxone (buprenorphine) for many years, be tapered off the medication eventually?

Should Patients on Long-Term Suboxone Be Tapered Off Eventually?

No—patients stable on long-term buprenorphine (Suboxone) should generally remain on maintenance therapy indefinitely rather than being tapered off, as tapering leads to significantly higher rates of relapse and return to opioid use. 1

The Evidence Against Routine Tapering

The strongest and most recent evidence demonstrates that tapering buprenorphine is substantially less effective than continuing maintenance therapy:

• In a randomized controlled trial of prescription opioid dependence, patients who tapered off buprenorphine had only 35.2% opioid-negative urine samples compared to 53.2% in those continuing maintenance 1
• Only 11% of patients in the taper group completed the trial successfully, compared to 66% in the maintenance group 1
• Patients who tapered reported more days per week of illicit opioid use (1.27 days vs 0.47 days) and had fewer consecutive weeks of abstinence (2.70 weeks vs 5.20 weeks) 1

Real-world data confirms these findings: In a 12-year retrospective study, only 15% of patients attempted to taper off buprenorphine, and among those who did taper, 61% returned to buprenorphine treatment within two years 2. Another study found that zero patients successfully completed methadone tapering in a program that supported both tapering and indefinite maintenance 3.

When Maintenance Should Continue

Buprenorphine maintenance is the appropriate long-term treatment for opioid use disorder, similar to how antihypertensives or antihyperglycemics are continued indefinitely for chronic conditions 4. The FDA label explicitly states that buprenorphine should not be abruptly discontinued in physically-dependent patients 5.

Growing evidence, including randomized clinical trials, supports maintenance with buprenorphine for patients with chronic non-cancer pain and opioid dependence 6. Longitudinal studies indicate that most opioid agonist-using patients are not able to successfully complete tapering attempts 3.

When Tapering May Be Considered

Tapering should only be attempted when all of the following conditions are met 4:

• Patient strongly desires to taper and demonstrates sustained stability (typically years of treatment) 4, 2
• Psychiatric comorbidities are addressed, including depression and anxiety 4
• No active opioid use disorder criteria are present on DSM-5 assessment 4
• Comprehensive support systems are in place, including behavioral therapy and close monitoring 4

Safe Tapering Protocol (If Attempted)

If tapering is pursued despite the evidence against it, use an extremely slow, collaborative approach 4:

Pre-Taper Requirements

• Establish a collaborative agreement documenting patient understanding and clinician commitment to non-abandonment 4
• Rule out active opioid use disorder—patients with OUD require maintenance therapy, not tapering 4
• Address all psychiatric comorbidities before initiating dose reduction 4

Tapering Schedule

• Reduce by approximately 10% of the current dose (not the original dose) every 2-4 weeks 4
• Each new dose should be 90% of the previous dose rather than using straight-line reductions 4
• Maintain each dose for 2-4 weeks before further reduction 4
• The target dose may not be zero—some patients benefit from resumption at lower doses after complete tapering 4

Managing Withdrawal Symptoms

• Use clonidine 0.1-0.2mg every 6 hours for autonomic symptoms 4
• Lofexidine 0.1mg every 8-12 hours for opioid withdrawal 4
• Tizanidine 2-8mg every 8 hours as alternative if hypotension concerns arise 4
• Trazodone, gabapentin, or mirtazapine for insomnia and anxiety 4
• Loperamide for gastrointestinal symptoms 4

Essential Support Measures

• Cognitive behavioral therapy during taper reduces dropout risk and improves outcomes 4
• Daily or frequent contact during active tapering improves success rates 4
• Immediate intervention availability when patient experiences distress is crucial 4

Critical Pitfalls to Avoid

Never abandon patients who struggle with tapering or relapse 6, 4. Abrupt withdrawal or major dose reduction of buprenorphine is unacceptable medical care except in extreme cases such as confirmed diversion or serious medical toxicity 4.

Do not assume all deterioration represents dependence—withdrawal symptoms, pain exacerbation, and psychiatric instability are common during tapering 4. Patients attempting tapers should be informed about the difficulty involved and monitored closely for signs of instability 3.

Avoid making "cold referrals" to other clinicians without confirmed acceptance 4. Even in cases requiring discontinuation, there remains risk of overdose during transitions of care 4.

Alternative to Complete Discontinuation

For patients with poor response to taper but without active opioid use disorder, consider switching to very low-dose buprenorphine maintenance rather than complete discontinuation 6, 4. This approach acknowledges that some patients have "complex persistent dependence" requiring ongoing medication support 4.

A novel approach using a single injection of 100mg extended-release buprenorphine has shown promise in facilitating discontinuation by mitigating prolonged withdrawal symptoms in patients previously unable to taper fully 7.

The Bottom Line

The medical community must work to address barriers to long-term maintenance rather than promoting tapering 2. Buprenorphine maintenance therapy is highly effective and safe for opioid use disorder 8, and sudden cessation is inappropriate and potentially dangerous 4. Most patients who successfully taper will return to treatment, making indefinite maintenance the evidence-based standard of care for the majority of patients.