What are the considerations for stopping or changing medications in a patient taking Suboxone (buprenorphine/naloxone) for opioid use disorder, Abilify (aripiprazole) and fluoxetine for psychiatric conditions, trazodone for insomnia, and omeprazole for gastrointestinal issues?

Medication Management in Opioid Use Disorder with Psychiatric Comorbidities

Critical Priority: Continue Suboxone Indefinitely

Do not discontinue or taper Suboxone (buprenorphine/naloxone) in this patient—discontinuation precipitates withdrawal and dramatically increases relapse risk to more dangerous opioids. 1 Buprenorphine for opioid use disorder should never be reduced or discontinued to comply with opioid dose guidelines due to its ceiling effect on respiratory depression. 1 There is no maximum recommended duration of maintenance treatment, and patients may require treatment indefinitely. 1

Suboxone: Non-Negotiable Maintenance

• Suboxone is FDA-approved specifically for opioid use disorder and represents medication-assisted treatment that reduces mortality by up to threefold compared to no medication. 2, 3
• The therapeutic dose range is 8-16 mg daily, with a target of 16 mg daily for most patients. 3
• Discontinuing buprenorphine therapy precipitates withdrawal and increases the risk of relapse to illicit opioid use. 1
• Buprenorphine maintenance therapy demonstrates clinical equivalence to methadone in retaining patients in treatment and reducing illicit opioid use. 3

Abilify (Aripiprazole): Reassess Necessity and Monitor

The need for continued Abilify treatment should be reassessed periodically, using the smallest dose and shortest duration producing satisfactory clinical response. 4

Key Monitoring Requirements:

• Screen for tardive dyskinesia at each visit—if signs appear, drug discontinuation should be considered, though some patients may require treatment despite the syndrome. 4
• Monitor for metabolic changes including hyperglycemia (fasting glucose at baseline and periodically), dyslipidemia, and weight gain. 4
• Patients with diabetes or risk factors (obesity, family history) require regular fasting blood glucose monitoring. 4
• Screen for QT-prolonging medication interactions when using aripiprazole with buprenorphine, as concomitant use may be contraindicated. 1

Discontinuation Considerations:

• If the psychiatric indication is well-controlled and stable, consider tapering Abilify to the lowest effective dose or discontinuing if alternative treatments are available. 4
• Chronic antipsychotic treatment should be reserved for patients with chronic illness known to respond to antipsychotics and for whom alternatives are not available or appropriate. 4

Fluoxetine: Continue with Monitoring

Continue fluoxetine for depression/anxiety management, as untreated psychiatric comorbidity predicts opioid taper discontinuation and poor outcomes. 2

Monitoring and Management:

• Screen all patients on Suboxone for depression using the two-question screen, with PHQ-9 for formal diagnosis; refer for psychiatric evaluation if score ≥10. 3
• Fluoxetine is generally well-tolerated with SSRIs showing efficacy in psychiatric conditions. 2
• Typical SSRI side effects include sweating, tremors, nervousness, insomnia or somnolence, dizziness, and gastrointestinal/sexual disturbances. 2
• If discontinuation is planned, taper over 10-14 days to limit withdrawal symptoms. 2

Trazodone: Continue for Insomnia Management

Continue trazodone as it effectively manages insomnia and anxiety during opioid maintenance therapy without interfering with Suboxone. 2

• Trazodone is specifically mentioned as beneficial for short-term use in managing anxiety, insomnia, and irritability during opioid treatment. 2
• It does not counteract physiologic opioid withdrawal but mitigates associated symptoms. 2
• No specific drug interactions with buprenorphine are documented that would require discontinuation. 2

Omeprazole: Continue as Indicated

Continue omeprazole for gastrointestinal symptom management—there are no contraindications with this medication regimen. 2

• Omeprazole addresses gastrointestinal discomfort that may be related to underlying conditions or medication side effects. 2
• Patients on opioid maintenance therapy commonly experience gastrointestinal symptoms that benefit from proton pump inhibitor therapy. 2

Critical Drug Interaction Warning

Avoid concurrent benzodiazepines with Suboxone whenever possible due to increased risk of fatal respiratory depression. 1 If benzodiazepines are necessary, use the lowest effective dose with close monitoring. 1

Comprehensive Monitoring Protocol

At Each Visit:

• Document any opioid relapses, reemergence of cravings or withdrawal symptoms. 5
• Perform random urine drug testing to monitor for illicit substance use. 5, 3
• Check state prescription drug monitoring program records. 5
• Assess for signs of tardive dyskinesia (involuntary movements, especially facial). 4
• Screen for depression and anxiety symptoms. 3

Periodic Testing:

• Fasting blood glucose (baseline and periodically for patients on Abilify). 4
• Hepatitis C and HIV screening. 3
• Lipid panel for metabolic monitoring. 4

Common Pitfalls to Avoid

1. Never taper or discontinue Suboxone to reduce "opioid burden"—buprenorphine for OUD is not subject to opioid tapering guidelines due to its safety profile. 1
2. Do not abruptly stop Abilify without assessing for withdrawal or rebound psychiatric symptoms—taper gradually if discontinuation is indicated. 4
3. Do not ignore metabolic monitoring on Abilify—hyperglycemia can be severe and life-threatening. 4
4. Sporadic opioid use in the first months of Suboxone treatment is not uncommon and should be addressed with increased visit frequency and behavioral therapy engagement, not medication discontinuation. 5