Just over a decade ago the landscape of addiction medicine changed dramatically when Suboxone (buprenorphine/naloxone) entered the picture. Touted as a wonder drug for those combating addiction to painkillers and heroin, Suboxone was scientifically shown to be highly effective in eliminating an addict’s cravings, allowing them to regain a sense of wellness and creating the psychological space necessary to begin the hard work of recovery.
Unlike methadone, Suboxone didn’t need to be administered in an opioid treatment clinic, making it simpler to prescribe and less stigmatized. This change is overwhelmingly to the good, but the availability of the medication in less controlled environments has also resulted in some predictable concerns.
From Miracle Drug To Public Health Concern
In the right hands, Suboxone continues to be a very effective medication for patients who are looking to withdraw from opiates safely and comfortably. But in the wrong hands, including those physicians who aren’t as knowledgeable about the importance of comprehensive care for successful addiction treatment, it has the potential to be misused.
As prescriptions for the drug began to increase, patients often found that they didn’t need as much of the medication as they were prescribed. As a result, the surplus Suboxone made its way onto the streets where it was obviously not used in the appropriate way for which it had been prescribed.
Suddenly, the once “miracle” drug became the subject of public health concerns as issues such as medication diversion, for recreational use hit the media. Additionally, concerns began to arise around the advisability of patients staying on the medication long term, or forever.
Many, if not most, individuals prescribed Suboxone as part of their addiction treatment have a goal of wanting to eventually wean off of it and live a life free of opioids entirely.
Is Getting Off Of Suboxone Really Possible?
The short answer is yes. The long answer is that it takes time and a collaborative effort between the patient and the treatment team.
Unequivocally, one of the robust findings in addiction medicine is that people who attempt to go off of it relapse more than those who stay on it. Period. Many doctors have taken this to mean that it’s best just to put people on Suboxone and leave them on a maintenance dose indefinitely. I see a couple of problems with that strategy.
First, we are still learning about best practices in tapering people off of Suboxone, and the prevailing wisdom that people should stay on Suboxone indefinitely is impacted by the many people who have tried to get off Suboxone in a less-than-optimal way, with inadequate monitoring, therapy and psychosocial supports.
Second, although long-term Suboxone may prove to be the best “population health management strategy” for persons with opioid addiction, that doesn’t mean that every patient will want that, and we owe it to those patients who want to live opioid-free to identify the elements necessary for successful tapering.
There Are No Shortcuts: It Takes Time And Hard Work
Tapering off of Suboxone takes time, typically six to twelve months. But the benefit is that this time is a therapeutic opportunity to continue to engage the patient in comprehensive treatment, to keep talking to them about their recovery process, and to continue holding them accountable.
If they’ve already been on Suboxone for months, and they’re receiving the type of comprehensive care necessary to achieve recovery, then they’re hopefully well on their way to developing a lifestyle and skill-set that will continue when they are off of Suboxone.
They’re doing the hard work of recovery, and many are ready to start the process of tapering off of opioids completely.
A Therapeutic Alliance: The Key To Successful Tapering
The majority of patients who wish to get off of Suboxone have something in common: they are fearful of withdrawal symptoms. In fact, most are more than afraid of withdrawal—they’re terrified!
Underneath that fear of withdrawal is a fear of suffering. They’re worried that if they taper off too quickly, they’ll find themselves too sick to work or too sick to take care of their children. They’re scared that if it doesn’t go well and they relapse, that they will lose the ability to do all of the great things that are available to people enjoying the full life that recovery can bring.
This fear can be overcome in the context of a positive therapeutic alliance between the doctor and patient. What this means is that the patient knows their doctor, trusts their doctor, and believes their doctor when she tells them that she won’t let them fall into an abyss of suffering. This trust is paramount to successful tapering; I would go so far as to say that it is nearly impossible without it.
When a working therapeutic alliance is present, then every aspect of the patient’s response to the tapering process can be addressed. If the patient doesn’t want to decrease the dose one month, the dose is not decreased. If the patient feels nervous about the amount of reduction, then a slower, more conservative approach can be taken.
This patient-driven approach ensures that the individual continues to feel in control, comfortable and safe with the rate of progress.
A Gradual Process
I typically decrease Suboxone for my patients once a month, occasionally every two weeks, for patients who have been on a maintenance dose. The reason for this is it has a really long half-life, which means that it has a long duration of action. This makes it optimal to wait for two to four weeks before dose decreases in a medically monitored outpatient taper.
For instance, if a dose is decreased from 8mg to 6mg, it will take the body almost a week in order to feel the full impact of the dose change. This means that even though the patient’s dose is now 6mg, their blood level is only very gradually coming down from the blood level of an 8mg dose.
Once that first week has passed and the person has adjusted to the full impact of the new dose, they can try it on for size and evaluate the effect. How do they feel? Is it manageable? Are they able to continue all of the positive behaviors and activities that they were able to on the higher dose?
The answers to these questions will then determine how successful that particular dose decrease was and help me determine if and when the patient will be ready for further reduction. It’s not a one-size-fits-all program. It’s a slow, individualized process.
What Patients Can Expect
Other than feeling a bit tired for a couple of days when the dose is initially decreased, when the taper is gradual enough patients don’t typically feel a notable difference until they get down to a lower dose, around 2 to 4mg.
The reason for this is because Suboxone is so long lasting and sticks to the opiate receptors so tightly, at doses over 4mg there is still a fairly high percentage of receptors occupied by the drug. Less than 50% receptor occupancy rate isn’t reached until the patient is around a 2mg dose.
Doctors can use this information to understand the tapering process and better assist patients with a slow, systematic, medically-managed approach.
As patients begin to realize that, even if they don’t feel great for a couple of days following a dose decrease, that feeling passes quickly, and their fear of intense withdrawal symptoms subsides.
A Safety Net At The Finish Line
When the patient finally has the end of a life on opioids in sight and has reached that low dose, there are additional tools to help them complete the taper.
Even though the pill or the film form of Suboxone isn’t made in a dose smaller than 2mg, the film can be cut up so that smaller, incremental dose decreases can be made below the 2mg mark. The patient can continue to follow the same slow, systematic method of tapering, but now with much smaller doses: 2mg to 1 mg, 1 mg to ½ mg.
By the time the patient takes that final step off of the Suboxone, there has been plenty of time for them to adjust and there should be little to no withdrawal symptoms. They may feel a bit tired for a couple of days, but it eventually passes and hopefully is also counteracted by the growing realization that they have finally reached their goal.
I will sometimes use, if indicated, an opioid receptor blocker, such as naltrexone, to help the patient make this final transition toward success. This may offer one additional safety net with its opiate receptor blockade effect as well as its anti-craving properties.
It’s Not for Everyone
This is simply one way to taper patients off Suboxone which I have found to be safe and effective. Just as there are no shortcuts to this methodical process, there are no sure outcomes.
Some patients will absolutely need to be on Suboxone indefinitely. Some individuals simply don’t tolerate the tapering process well, no matter how slow and methodical it is. It may be that their brain was more impacted from their drug use or it may simply be that their physiology is different enough that completely getting off of Suboxone is not an option. Whatever the reason or mechanism, we are still learning more about this process and many people are best served by receiving long-term Suboxone. These individuals have still done all of the hard work of recovery, and the opportunity to revisit tapering is still available down the road.
One unique patient population who may fall into the category of long-term Suboxone use is those patients with both addictive disorders and chronic pain. While many chronic pain sufferers actually do better off of opiates, there are exceptions. Suboxone is an excellent medication for these individuals because it can treat both addiction and pain when combined with therapy and psychosocial support.
An Opportunity For True Success
Getting off of Suboxone is an achievable goal for some patients. With the right collaborative relationship with their physician, patients have no reason to fear severe withdrawal symptoms or believe that a life free of opiates is not attainable. The entire process of a safe taper in a medically managed environment can of course be challenging, but it can also be incredibly rewarding as patients work toward their ultimate recovery goal.