What is the appropriate tapering schedule for sublingual buprenorphine in a patient taking 8 mg twice daily?

Buprenorphine Taper Schedule for a Patient on 8 mg Twice Daily

For a stable adult taking 16 mg daily buprenorphine (8 mg BID), reduce the dose by approximately 10% per month—starting at 14 mg daily in month 1, then 13 mg, 12 mg, and so on—while monitoring withdrawal symptoms at each step and pausing or slowing the taper if symptoms become intolerable. 1

Evidence Strongly Favors Maintenance Over Tapering

Before proceeding with any taper, you must understand that maintenance therapy is substantially more effective than tapering for preventing relapse in stable adults with opioid use disorder. 1 The CDC explicitly recommends offering buprenorphine as 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 illicit opioids. 1 There is no maximum recommended duration for buprenorphine maintenance—patients may require treatment indefinitely. 1

If the patient is requesting discontinuation despite these risks, proceed only after shared decision-making that documents the substantially higher relapse risk.

Recommended Monthly Taper Protocol

The standard evidence-based taper reduces the current dose by approximately 10% per month, which is better tolerated than faster schedules, especially for patients on long-term therapy. 1, 2 For your patient currently taking 16 mg daily (8 mg BID):

Month-by-Month Dosing Schedule

Month	Daily Dose	Approximate % Reduction
Baseline	16 mg	—
1	14 mg	12.5%
2	13 mg	7%
3	12 mg	8%
4	11 mg	8%
5	10 mg	9%
6	9 mg	10%
7	8 mg	11%
8	7 mg	12.5%
9	6 mg	14%
10	5 mg	17%
11	4 mg	20%
12	3 mg	25%
13	2 mg	33%
14	1 mg	50%
15	0.5 mg	50%
16	0.5 mg every other day	—
17	Discontinue	—

1

Patients typically require 2–4 weeks to stabilize at each lower dose during a buprenorphine taper, though this varies significantly based on individual factors. 2 The stabilization period is longer for patients who have been on buprenorphine for extended periods compared to those on shorter-term therapy. 2

Critical Management Principles

Monitoring and Dose Adjustments

• Use the Clinical Opiate Withdrawal Scale (COWS) at each monthly visit to objectively grade withdrawal severity: scores 5–12 indicate mild, 13–24 moderate, 25–36 moderately severe, and >36 severe withdrawal. 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 (0.5 mg) 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 Symptoms

Maximize adjunctive medications to control withdrawal symptoms throughout the 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 or gabapentin 300–600 mg three times daily for insomnia and anxiety 1
• Loperamide 2–4 mg as needed for diarrhea 1
• Anti-emetics such as promethazine or ondansetron for nausea 1

Protracted Withdrawal

Anticipate protracted withdrawal symptoms (dysphoria, irritability, insomnia, anhedonia, vague malaise) that may persist for months after dose reductions or elimination. 1, 2 These should be treated aggressively with the adjunctive medications listed above. 1

Criteria to Abort the Taper and Resume Maintenance

Resume maintenance therapy immediately if: 1

• Persistent withdrawal symptoms occur despite maximized adjunctive medications
• The patient requests discontinuation of the taper
• Emergence of significant anxiety, depression, or opioid misuse during the taper
• The patient cannot function in daily life because of withdrawal symptoms

Written Taper Agreement

Before initiating any taper, create a formal written agreement that includes: 1

• Clinical rationale for discontinuation
• Start and planned end dates (minimum 10 months for this patient)
• Detailed month-by-month dose-reduction schedule
• Clear outline of withdrawal risks and adjunctive-medication strategies
• Patient commitments to attend scheduled visits and contact the clinician promptly if problems arise
• Regular urine toxicology and prescription-monitoring checks
• Explicit provisions stating the clinician will not abandon the patient if the taper fails and will promptly resume maintenance treatment 1

Safety Warnings

• Patients face a dramatically increased risk of overdose if they resume illicit opioid use after losing tolerance during the taper. 1
• Reducing buprenorphine by more than 10% per month (i.e., a rapid taper) is linked to higher patient dropout rates and increased relapse to illicit opioid use. 1
• Abruptly returning to a previously prescribed higher buprenorphine dose after taper markedly increases overdose risk. 1

Alternative: Faster Taper (Not Recommended for Long-Term Patients)

A research study showed that a 4-week taper yields higher abstinence rates (≈50%) than 1- or 2-week tapers (≈20% and 16%), but this duration is far shorter than the multi-month taper recommended by guidelines and is associated with much higher relapse rates than maintenance therapy. 1 In a randomized trial, patients in the taper group had a mean of only 35.2% opioid-negative urine samples compared to 53.2% in the maintenance group, and only 11% of taper patients completed the trial versus 66% of maintenance patients. 3

Common Pitfalls to Avoid

• Initiating a taper without documenting that the patient understands the substantially higher relapse risk compared to maintenance therapy 1
• Tapering faster than 10% per month in patients on long-term therapy 1, 2
• Failing to maximize adjunctive medications before declaring the taper intolerable 1
• Not pausing the taper when withdrawal symptoms emerge 1
• Abandoning the patient if the taper fails rather than promptly resuming maintenance 1