What is the safest tapering protocol for Suboxone (buprenorphine‑naloxone) in a stable adult patient who is not pregnant and has no severe psychiatric comorbidity?

How to Safely Wean Off Suboxone

For a stable adult on Suboxone, taper at approximately 10% of the current dose per month—or even slower—using a collaborative, symptom-driven approach with aggressive management of withdrawal symptoms and close monthly follow-up. 1, 2

Critical Pre-Taper Considerations

Before initiating any taper, you must address several key factors that predict success or failure:

• Screen for active opioid use disorder (OUD) using DSM-5 criteria; patients meeting criteria for active OUD should remain on indefinite maintenance therapy rather than taper, because discontinuation dramatically increases overdose and relapse risk. 3, 2, 4
• Treat psychiatric comorbidities first—depression, anxiety, and insomnia must be stabilized before dose reduction begins, as untreated mental health conditions predict taper failure. 2
• Establish a collaborative taper agreement that documents the patient's understanding, commitment to communicate difficulties, and your commitment to non-abandonment if the taper becomes intolerable. 2, 4
• Provide naloxone kits immediately when starting the taper, because patients face dramatically increased overdose risk if they return to illicit opioids after losing tolerance. 4

Evidence-Based Taper Schedule

The CDC and Mayo Clinic recommend the following approach for patients who have been on buprenorphine for ≥1 year: 1, 2, 4

Month-by-Month Taper Protocol (Starting from 8 mg Daily):

• Month 1: Reduce to 7.2 mg daily (10% reduction) 3
• Month 2: Reduce to 6.5 mg daily 3
• Month 3: Reduce to 5.8 mg daily 3
• Month 4: Reduce to 5.2 mg daily 3
• Month 5: Reduce to 4.7 mg daily 3
• Month 6: Reduce to 4.2 mg daily 3
• Month 7: Reduce to 3.8 mg daily 3
• Month 8: Reduce to 3.4 mg daily 3
• Month 9: Reduce to 3.0 mg daily 3
• Month 10: Reduce to 2.7 mg daily 3
• Month 11: Reduce to 2.4 mg daily 3
• Month 12: Reduce to 2.2 mg daily 3

Continue this pattern until reaching the lowest available dose, then extend the dosing interval (e.g., every other day, then every third day) rather than continuing to reduce the dose. 1, 3

Key Dosing Principles

• Each new dose should be approximately 90% of the previous dose rather than using fixed decrements. 2
• Maintain each dose for 2–4 weeks before further reduction to assess tolerance. 2
• 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. 4
• For patients struggling with the 10% monthly taper, slow to 10% every 2 months or even slower. 1, 4

Aggressive Symptomatic Management

Withdrawal symptoms must be treated aggressively to prevent taper failure: 3, 2, 4

Autonomic Symptoms (sweating, tachycardia, hypertension, anxiety):

• Clonidine 0.1–0.2 mg every 6–8 hours 3, 2, 4
• Lofexidine 0.1 mg every 8–12 hours 2
• Tizanidine 2–8 mg every 8 hours (if hypotension is a concern) 2

Insomnia and Anxiety:

• Trazodone 50–100 mg at bedtime 3, 2
• Gabapentin 300–600 mg three times daily 3, 2
• Mirtazapine 15–30 mg at bedtime 2

Gastrointestinal Symptoms:

• Loperamide 2–4 mg as needed for diarrhea 3, 2
• Promethazine or ondansetron for nausea 3, 2

Monitoring and Follow-Up Requirements

• Monthly face-to-face visits minimum during active tapering to assess withdrawal severity using the Clinical Opiate Withdrawal Scale (COWS). 4
• Utilize team members (nurses, pharmacists, behavioral health professionals) for telephone or telehealth contact between visits. 4
• Provide immediate intervention availability when the patient experiences distress—daily or frequent contact during active tapering improves success rates. 2
• Screen for hepatitis C and HIV during the withdrawal process. 4

Managing Taper Difficulties

When patients struggle to tolerate the taper: 1, 2, 4

• Pause the taper entirely and restart when the patient is ready—tapers may need to be paused and restarted multiple times. 1, 4
• Slow the taper rate further—some patients may need reductions every 2 months rather than monthly, or even slower. 1, 4
• Maximize adjunctive medications for withdrawal symptoms as described above. 1
• Increase behavioral support—cognitive behavioral therapy and interdisciplinary approaches reduce dropout risk and improve functional outcomes. 2
• Consider resuming maintenance therapy if persistent withdrawal symptoms occur despite adjunctive medications, as the target dose may not necessarily be zero. 3, 2

Protracted Withdrawal Syndrome

Months after completing the taper, patients may experience protracted withdrawal symptoms including dysphoria, irritability, insomnia, anhedonia, vague sense of being unwell, and increased pain sensitivity—these should be anticipated and treated. 3, 2

Critical Safety Warnings

• Never abruptly discontinue or make major dose reductions except in extreme cases such as confirmed diversion or serious medical toxicity—abrupt withdrawal is unacceptable medical care. 2
• Patients face dramatically increased overdose risk if they return to illicit opioids after losing tolerance during the taper. 1, 4
• Before reversing a taper (increasing the dose back up), carefully assess and discuss with the patient the benefits and risks of increasing opioid dosage. 1
• Remain alert for signs of anxiety, depression, and opioid misuse that might be revealed by the taper and provide treatment or arrange for management of these comorbidities. 1

Common Pitfalls to Avoid

• Do not make "cold referrals" to other clinicians without confirmed acceptance. 2
• Do not abandon patients who struggle with the taper—your commitment to non-abandonment is essential. 2
• Do not assume all deterioration is dependence—psychiatric comorbidities often emerge during tapering. 2
• Do not taper patients with active opioid use disorder—they require maintenance therapy, not discontinuation. 2, 4

Alternative: Extended-Release Buprenorphine for Final Discontinuation

For patients who reach a low dose (e.g., 2–4 mg daily) but cannot tolerate complete discontinuation due to prolonged withdrawal symptoms, a single 100 mg injection of extended-release buprenorphine may facilitate final cessation by mitigating debilitating withdrawal symptoms over several weeks. 5

Restarting Buprenorphine After Failed Taper

If the patient relapses to opioid use after discontinuing buprenorphine: 3, 4

• The patient MUST be in mild-to-moderate opioid withdrawal (COWS ≥8) before restarting buprenorphine to avoid precipitated withdrawal. 3, 4
• Wait at least 12 hours after short-acting opioids, 24 hours after extended-release formulations, or 72 hours after methadone before administering buprenorphine. 3, 4
• Start with 4–8 mg sublingual based on withdrawal severity, then reassess after 30–60 minutes. 3, 4