What taper schedule should be used for an adult with opioid use disorder who is medically stable, not pregnant, not severely withdrawing, and currently taking Suboxone (buprenorphine/naloxone) 4 mg twice daily, to reach 1 mg twice daily before discontinuation?

Suboxone Taper from 4 mg BID to 1 mg BID

For a medically stable adult on Suboxone 4 mg twice daily (8 mg total daily), reduce the dose by approximately 10% per month using a slow, symptom-driven taper with aggressive adjunctive medication support, reaching 1 mg BID (2 mg total daily) over approximately 6 months before considering further discontinuation. 1

Critical Context: Maintenance vs. Taper

• Buprenorphine maintenance therapy is substantially more effective than tapering for preventing relapse in stable adults with opioid use disorder, with maintenance demonstrating superior outcomes in reducing illicit opioid use and mortality. 1, 2
• The CDC explicitly recommends offering buprenorphine as medication-assisted maintenance rather than detoxification because maintenance better prevents relapse. 1
• There is no maximum recommended duration of maintenance treatment—patients may require treatment indefinitely, and discontinuing buprenorphine precipitates withdrawal and dramatically increases relapse risk to more dangerous opioids. 1

Recommended Monthly Taper Schedule

Starting from 8 mg daily (4 mg BID), reduce by approximately 10% per month: 1

Month	Total Daily Dose	Dosing Schedule	% Reduction
1	7.2 mg	4 mg AM + 3.2 mg PM	10%
2	6.5 mg	3.5 mg BID	~10%
3	5.8 mg	3 mg AM + 2.8 mg PM	~10%
4	5.2 mg	2.6 mg BID	~10%
5	4.7 mg	2.5 mg AM + 2.2 mg PM	~10%
6	4.2 mg	2.1 mg BID	~10%
7	3.8 mg	2 mg AM + 1.8 mg PM	~10%
8	3.4 mg	1.7 mg BID	~10%
9	3.0 mg	1.5 mg BID	~10%
10	2.7 mg	1.5 mg AM + 1.2 mg PM	~10%
11	2.4 mg	1.2 mg BID	~10%
12	2.2 mg	1.1 mg BID	~10%
Target	2.0 mg	1 mg BID	–

Key Taper Principles

• A 10% dose reduction per month is generally better tolerated than faster tapers, especially for patients on long-term therapy. 1
• If the patient cannot tolerate a 10% monthly reduction, slow the taper to a 10% reduction every two months or even slower, maintaining each dose for 2–4 weeks before the next change. 1
• Pause the taper entirely when withdrawal becomes intolerable; restart only when the patient feels ready—multiple pauses may be required. 1
• When the smallest available dose is reached, extend the dosing interval (e.g., every other day, then every third day) rather than continue dose reductions. 1

Adjunctive Medications for Withdrawal Management

Maximize adjunctive medications to control withdrawal symptoms during taper: 1

• Clonidine 0.1–0.2 mg every 6–8 hours for autonomic symptoms (sweating, tachycardia, hypertension, anxiety) 1
• Trazodone 50–100 mg at bedtime for insomnia 1
• Gabapentin 300–600 mg three times daily for anxiety and insomnia 1
• Loperamide 2–4 mg as needed for diarrhea 1
• Promethazine or ondansetron for nausea and vomiting 1

Monitoring and Follow-Up

• Schedule monthly follow-up visits to assess withdrawal symptoms, adjust taper speed, and optimize adjunctive medications. 1
• Use the Clinical Opiate Withdrawal Scale (COWS) to objectively assess withdrawal severity at each visit; scores of 5–12 indicate mild withdrawal, 13–24 moderate, 25–36 moderately severe, and >36 severe. 3
• Remain alert for emerging anxiety, depression, or opioid misuse during tapering and provide appropriate treatment or referral. 1

Criteria to Abort the Taper and Resume Maintenance

Resume full-dose buprenorphine maintenance therapy if: 1

• Persistent withdrawal symptoms occur despite maximized adjunctive pharmacologic support
• The patient explicitly requests discontinuation of the taper
• Emergence of significant anxiety, depression, or opioid misuse during the taper

Management of Protracted Withdrawal

• Anticipate and treat protracted withdrawal symptoms (dysphoria, irritability, insomnia, anhedonia, vague malaise) that may appear months after dose reductions. 1
• Aggressive use of adjunctive medications (clonidine, lofexidine, tizanidine, trazodone, gabapentin, loperamide, anti-emetics) is recommended to control these lingering effects. 1

Safety Warnings

• Patients face a dramatically increased risk of overdose if they resume illicit opioid use after losing tolerance during the taper. 1
• Abruptly returning to a previously prescribed higher buprenorphine dose after taper markedly increases overdose risk. 1
• Before reversing a taper by increasing the buprenorphine dose, carefully assess and discuss the potential benefits and risks with the patient. 1

Pre-Taper Documentation

• Require a written collaborative agreement that records the patient's understanding of withdrawal risks, a commitment to maintain communication during distress, and the clinician's pledge not to abandon care if taper difficulties arise. 1

Common Pitfalls to Avoid

• Tapering too rapidly (faster than 10% per month) is associated with higher dropout rates and relapse, especially in patients taking high levels of opioids. 3
• Failing to maximize adjunctive medications leads to unnecessary suffering and taper failure. 1
• Not pausing the taper when withdrawal becomes intolerable increases the risk of relapse to illicit opioids. 1
• Continuing the taper despite patient request to stop violates patient autonomy and increases dropout risk. 1