How can a patient with chronic hip pain, long‑term opioid dependence now on daily Suboxone (buprenorphine/naloxone), and significant medical illness safely discontinue Suboxone?

Buprenorphine Discontinuation Strategy for Chronic Pain and Opioid Dependence

For a patient with chronic hip pain who is stable on daily Suboxone (buprenorphine/naloxone) but wishes to discontinue, the evidence strongly recommends indefinite maintenance therapy rather than tapering, because discontinuation dramatically increases relapse risk and mortality. 1 However, if the patient insists on stopping despite counseling about these risks, a very slow taper over 10–12 months combined with aggressive symptom management offers the safest approach. 1

Why Maintenance Is Preferred Over Discontinuation

• Buprenorphine maintenance therapy is substantially more effective than tapering for preventing relapse to illicit opioids in stable adults. 1 The CDC explicitly recommends offering buprenorphine as long-term medication-assisted maintenance rather than detoxification because maintenance better prevents relapse. 1

• Discontinuing buprenorphine precipitates withdrawal and dramatically increases the risk of relapse to more dangerous opioids, including potential fatal overdose due to loss of tolerance. 1, 2 Patients who discontinue treatment face markedly elevated overdose risk if they return to illicit opioid use. 1

• There is no maximum recommended duration of buprenorphine maintenance—patients may require treatment indefinitely. 1 The American Society of Addiction Medicine emphasizes that buprenorphine for opioid use disorder should not be reduced or discontinued due to its ceiling effect on respiratory depression. 1

Structured Taper Protocol (If Patient Insists on Discontinuation)

If the patient cannot be persuaded to continue maintenance, implement a 10-month minimum taper with approximately 10% dose reduction per month, using a collaborative written agreement and monthly COWS monitoring. 1

Month-by-Month Taper Schedule

Month	Daily Dose	% Reduction	Clinical Action
Baseline	8 mg (current)	—	Establish written taper agreement [3]
1	7 mg	12.5%	COWS assessment, adjust adjunctive meds [1]
2	6 mg	14%	Monitor withdrawal symptoms [1]
3	5 mg	17%	Reassess readiness to continue [1]
4	4 mg	20%	Consider pausing if intolerable [1]
5	3 mg	25%	Increase adjunctive medication support [1]
6	2 mg	33%	Slow further if withdrawal severe [1]
7	1 mg	50%	Anticipate protracted symptoms [1]
8	0.5 mg	50%	Extend dosing interval next [1]
9	0.5 mg every other day	—	Continue interval extension [1]
10	Discontinue	—	Intensive follow-up for 6+ months [1]

• If the patient cannot tolerate 10% monthly reductions, slow the taper to 10% every two months or even slower. 1 Multiple pauses in the taper are expected and appropriate. 1

• When the smallest available dose (0.5 mg) is reached, extend the dosing interval (every other day, then every third day) rather than attempting further dose reductions. 1

Aggressive Adjunctive Symptom Management

Maximizing adjunctive medications is essential to control withdrawal symptoms during tapering and for months afterward. 1

Autonomic Symptoms (Sweating, Tachycardia, Hypertension, Anxiety)

• Clonidine 0.1–0.2 mg every 6–8 hours as needed for autonomic hyperactivity. 1, 4
• Lofexidine is an alternative alpha-2 agonist with fewer hypotensive effects. 5

Insomnia and Anxiety

• Trazodone 50–100 mg at bedtime for insomnia. 1
• Gabapentin 300–600 mg three times daily for anxiety and restlessness. 1

Gastrointestinal Symptoms

• Loperamide 2–4 mg as needed for diarrhea. 1, 4
• Antiemetics (promethazine or ondansetron) for nausea and vomiting. 1, 4

Protracted Withdrawal (Months After Discontinuation)

• Anticipate dysphoria, irritability, insomnia, anhedonia, and vague malaise that may persist for months after opioid elimination. 1 These protracted symptoms require ongoing treatment with the medications listed above. 1

Written Taper Agreement and Monitoring

Before starting the taper, establish a written collaborative agreement documenting the patient's understanding of withdrawal risks, commitment to maintain communication during distress, and the clinician's pledge not to abandon care if taper difficulties arise. 1 This agreement improves taper adherence and reduces failure rates. 1

Key Elements of the Taper Agreement 3

• Formal rationale for the taper (patient request to discontinue)
• Start date and planned end date (10+ months)
• Weekly or monthly reduction plan with specific doses
• Outline of withdrawal risks and management strategies
• Patient agreement to keep all scheduled appointments
• Patient agreement to contact the physician immediately if issues occur
• Regular urine toxicology and prescription monitoring checks
• No controlled substances from other physicians without prenotification
• Provisions for taper failure (see below)

Monthly Monitoring Requirements

• Administer the Clinical Opiate Withdrawal Scale (COWS) at each visit to objectively grade withdrawal severity: 5–12 = mild, 13–24 = moderate, 25–36 = moderately severe, >36 = severe. 1 COWS scores guide decisions to pause or slow the taper. 1

• Reducing buprenorphine by more than 10% per month is linked to higher dropout rates and increased relapse to illicit opioid use. 1 If COWS scores indicate moderate or worse withdrawal, pause the taper entirely. 1

Criteria to Abort the Taper and Resume Maintenance

Resume buprenorphine maintenance therapy immediately if any of the following occur: 1

• Persistent withdrawal symptoms despite maximized adjunctive pharmacologic support (clonidine, gabapentin, trazodone, loperamide, antiemetics at full doses). 1

• The patient explicitly requests discontinuation of the taper. 1 Multiple requests to stop the taper are common and should be honored. 1

• Emergence of significant anxiety, depression, or opioid misuse during the taper. 1 These signal that continuation may be unsafe. 1

• Patient reports inability to function in daily life due to withdrawal symptoms. 3

Alternative: Extended-Release Buprenorphine for Final Discontinuation

For patients who reach very low doses (≤2 mg daily) but cannot tolerate complete cessation, a single 100 mg injection of extended-release buprenorphine (Sublocade) may facilitate final discontinuation by mitigating prolonged withdrawal symptoms. 6 This approach has been reported in case series where patients transitioned from low-dose sublingual buprenorphine to a single extended-release injection, then successfully discontinued all buprenorphine. 6

Critical Safety Warnings

• Patients face dramatically increased overdose risk if they resume illicit opioid use after losing tolerance during the taper. 1 Provide take-home naloxone kits and overdose-prevention education at every visit. 1

• Never abruptly discontinue buprenorphine. 2 Abrupt cessation precipitates severe withdrawal and markedly increases relapse risk. 1, 2

• Before reversing a taper by increasing the buprenorphine dose, carefully assess and discuss the potential benefits and risks with the patient. 1 However, resuming maintenance is often the safest course. 1

Addressing the Patient's Concerns About "Being Reliant"

The patient's concern about being "fully reliant" on Suboxone reflects a common misunderstanding: buprenorphine maintenance is evidence-based medical treatment for opioid use disorder, not a sign of failure. 1 Just as patients with diabetes require insulin indefinitely, patients with opioid use disorder often require buprenorphine indefinitely. 1

• Buprenorphine has a ceiling effect on respiratory depression, making it far safer than full-agonist opioids. 1, 7 The risk of overdose death on buprenorphine maintenance is dramatically lower than the risk after discontinuation. 1

• The goal of treatment is not necessarily to be medication-free, but to achieve stable functioning, abstinence from illicit opioids, and improved quality of life. 2 Many patients achieve these goals while remaining on buprenorphine maintenance. 1

Common Pitfalls to Avoid

• Tapering too quickly (>10% per month) leads to treatment failure. 1 Slow tapers over many months are more successful. 1

• Failing to maximize adjunctive medications leaves patients suffering unnecessarily and increases dropout. 1

• Not having a written taper agreement reduces adherence and increases conflict when difficulties arise. 1

• Abandoning the patient if the taper fails. 3, 1 The agreement should explicitly state that the clinician will not abandon care and will resume maintenance if needed. 1

• Not providing naloxone kits and overdose education. 1 Patients who relapse after losing tolerance face high overdose risk. 1