Suboxone Strip Taper Protocol
For stable adults wishing to discontinue buprenorphine-naloxone film strips, implement a slow taper reducing the dose by approximately 10% per month over 10–12 months, maintaining each dose for 2–4 weeks before further reduction, with aggressive adjunctive symptom management and monthly follow-up. 1, 2
Critical Pre-Taper Considerations
Before initiating any taper, you must address psychiatric comorbidities—specifically depression and anxiety—because untreated mood disorders dramatically increase taper failure rates. 2 Establish a written collaborative agreement documenting the patient's understanding of withdrawal risks, commitment to communication during distress, and your commitment to non-abandonment (you will not discharge the patient if the taper becomes difficult). 3, 2
Common pitfall: Patients with active opioid use disorder (meeting DSM-5 criteria for moderate-to-severe OUD) should not be tapered; they require indefinite maintenance therapy because discontinuation precipitates withdrawal and dramatically increases relapse risk to more dangerous illicit opioids. 1, 2
Month-by-Month Taper Schedule
The CDC and Mayo Clinic endorse this structured protocol for patients maintained on buprenorphine for ≥1 year: 1
| Month | Daily Dose (mg) | % Reduction |
|---|---|---|
| Baseline | 8.0 | — |
| 1 | 7.0 | 12.5% |
| 2 | 6.0 | 14% |
| 3 | 5.0 | 17% |
| 4 | 4.0 | 20% |
| 5 | 3.0 | 25% |
| 6 | 2.0 | 33% |
| 7 | 1.0 | 50% |
| 8 | 0.5 | 50% |
| 9 | 0.5 every other day | — |
| 10 | Discontinue | — |
Each new dose should be approximately 90% of the previous dose rather than using straight-line reductions. 2 Maintain each dose for 2–4 weeks before the next reduction to allow assessment of tolerance. 2
When you reach the smallest available dose (0.5 mg), extend the dosing interval (every other day, then every third day) rather than attempting further dose cuts, because film strips cannot be reliably divided below 0.5 mg. 1, 4
Adjusting Taper Speed
If the patient cannot tolerate a 10% monthly reduction, slow the taper to 10% every two months or even slower. 1 Very small initial dose decreases (e.g., 0.5 mg reductions) address anticipatory anxiety and build confidence. 2
Pause the taper entirely when withdrawal becomes intolerable; restart only when the patient feels ready. 1, 2 Multiple pauses are expected and acceptable—this is not treatment failure. 1
Aggressive Adjunctive Symptom Management
Maximize pharmacological adjuvants to control withdrawal symptoms during the taper: 1, 2
- Clonidine 0.1–0.2 mg every 6–8 hours for autonomic symptoms (sweating, tachycardia, hypertension, anxiety) 1, 2
- Lofexidine 0.1 mg every 8–12 hours as an alternative for opioid withdrawal 2
- Tizanidine 2–8 mg every 8 hours if hypotension from clonidine is a concern 2
- Trazodone 50–100 mg at bedtime or gabapentin 300–600 mg three times daily for insomnia and anxiety 1
- Loperamide 2–4 mg as needed for diarrhea 1
- Promethazine or ondansetron for nausea 1
Behavioral Support Requirements
Cognitive behavioral therapy and interdisciplinary approaches reduce dropout risk and improve functional outcomes. 2 Daily or frequent contact during active tapering improves success rates, and immediate intervention availability when the patient experiences distress is crucial. 2
Managing Protracted Withdrawal
Months after opioid elimination, patients may experience protracted withdrawal symptoms—dysphoria, irritability, insomnia, anhedonia, or vague malaise. 3 Anticipate these symptoms and treat them aggressively with the adjunctive medications listed above. 3
Criteria to Abort the Taper
Resume maintenance therapy if: 3, 1
- Persistent withdrawal symptoms occur despite maximized adjunctive medications 3
- The patient requests discontinuation of the taper 1
- Emerging anxiety, depression, or opioid misuse develops 1
Abrupt withdrawal or major dose reduction of buprenorphine is unacceptable medical care except in extreme cases such as confirmed diversion or serious medical toxicity. 2 Even in those cases, there remains a risk of overdose during transitions of care. 2
Critical Safety Warnings
Patients face a dramatically increased risk of overdose if they resume illicit opioid use after losing tolerance during the taper. 1 Provide a take-home naloxone kit and overdose-prevention counseling at every visit. 1
Before reversing a taper by increasing the buprenorphine dose, carefully assess and discuss the potential benefits and risks with the patient. 1
Do not make "cold referrals" to other clinicians without confirmed acceptance—this constitutes patient abandonment. 2
Film-Splitting Technique (If Required)
If you need to split films for intermediate doses, use a ruler and razor blade to cut films in half only (not quarters). 4 Half films cut by this method pass USP content uniformity standards (acceptance values 9.8–10.4 for buprenorphine, 8.4–11.5 for naloxone). 4 Store split films in polybags at room temperature; both actives retain >97.7% potency for 7 days. 4
Quarter films do not meet weight variation or content uniformity standards and should not be used. 4