Stopping Suboxone

I recently received a question about stopping Suboxone (buprenorphine)…. I deleted the message but I remember the bulk of it, and I have a copy of my response. I thought that someone else out there may find it useful, so here it is:

The question:

I have decided to go off Suboxone after that was recommended to me by almost everybody. My doctor told me to taper off by going down to 2 mg per day, and then take 2 mg every other day, then every third day, and stopping after I get to every 4th day. I followed those instructions and I am taking it every other day, but I am now getting sick every other day. Is this a good way to stop Suboxone, or do you recommend another way?

My response:

I’m not certain who is giving you advice. More and more, the standard of care is to keep people on buprenorphine for at least a year, and many people stay on ‘remission treatment’ indefinitely– just as we do for other chronic illnesses. There is no evidence or truth to the idea that ‘it is harder to stop buprenorphine the longer you take it’; tolerance does not increase after reaching a plateau, usually in a month or so, and I have found that patients are more successful at stopping buprenorphine the further they get from the period of active use. There is no significant toxicity from the medication when it is taken properly; it is far safer than medications used to treat other illnesses, such as hypertension, elevated cholesterol, asthma, diabetes, or arthritis– let alone other potentially fatal illnesses like cancer.

If you DO go off buprenorphine, the method you described won’t generally work because of the pharmacokinetics of the drug. The plasma half-life of buprenorphine is 2-5 hours, but the elimination half life is over 30 hours. The volume of distribution of the drug increases with dose because of dose-dependent protein binding. Finally, the ceiling effect creates a non-linear relationship between blood level and pharmacologic effect. The practical result of these factors is that larger doses of buprenorphine produce opioid effects that last longer than smaller doses. A typical buprenorphine pain dose of 50-100 micrograms lasts for 6-8 hours, but in the super high doses used for addiction (8 mg equals 8000 micrograms), the opioid effects last much longer- allowing for once per day dosing.

As the dose is lowered, the effects of buprenorphine become shorter in duration. So the person tapering buprenorphine need to not only take smaller amounts each day, but must also divide that daily amount into two, then three, then maybe even four doses to avoid withdrawal symptoms at the end of the dosing interval.

On my forum, SuboxForum, people discuss the ‘liquefied taper method’– a method that I believe I was the first to describe, where a tablet of Suboxone is dissolved in a small amount of water, and doses are administered by drop from a medicine dropper or TB syringe. Any small medicine bottle and the included dropper can be used. I would suggest taking the time to calculate the microgram per milliliter concentration, and using the dropper to dose known amounts.  A TB syringe is more accurate, as it has the amounts marked on the side. For this purpose, a ‘cc’ is the same as an ‘ml’. There are 1000 micrograms per milligram (mg). I’ll leave the rest of the calculations to you!

Another option might be to use ‘Butrans’, a buprenorphine skin patch, after tapering to a low sublingual dose. The biggest patch releases 500 micrograms (or 0.5 mg) per day, and there are a couple smaller sizes with the smallest patch releasing 0.1 mg per day or 100 micrograms. One could taper down to a quarter of an 8 mg tab per day, and then change to the 0.5 mg patch. That sounds like a big drop, but only a small percentage of the sublingual dose of buprenorphine is absorbed– some estimates as low as 15% of the dose. By that estimate, a 2 mg sublingual dose of buprenorphine would be comparable to 0.5 mg of transdermal buprenorphine.

I wrote Butrans might be used because under current law, doctors cannot prescribe Butrans to treat addiction—and I assume that includes tapering off buprenorphine. Federal law that allows for use of controlled substances to treat opioid dependence (DATA 2000)—an exception to the Harrison Act— only allows use of medications that are indicated for opioid dependence. At the present time, Butrans is indicated for treating pain, and not for treating addiction. By my understanding of the law, doctors can use Butrans to taper patients off buprenorphine only if the indicated use for the buprenorphine is any condition other than addiction.

But again, do give some thought to whether you should be stopping buprenorphine, as the relapse rate for opioid dependence is, unfortunately, very high.

6 thoughts on “Stopping Suboxone”

  1. My son has been on Suboxone for a little over 2 years. He is gradually getting back to a happy place and is considering tapering. A while back you commented on patients staying on Suboxone until their early thirties (he is 25) and I wonder if you still feel the way you did then. Would you comment on this and on the current success of any patients you know who have tapered off? He is in no hurry and I will encourage a very long taper (if at all).

    Also, does his past history of addiction in anyway predict his success in tapering off. If he was using IV heroin will his chances of success be less that someone who used oral Vicodin?

  2. okay, here goes my son had been addicted to roxies, then got off of it and used methadone to ween himself off and used subuxone to ween himself off, all that is doing is prolonging the inevitable, he needed as most people that are on drugs need to do is to get off of all of it once and for all, so I took his subuxone away and he is going cold turkey, this is his 3rd week, he started out with a cold, runny nose, stuffy, then it hit him full force last week with the throwing up, hands and feed numb for a night, sore muscles, he takes lots of showers, he drinks still but has not eaten anything but a handful of food in a week, for 4 days straight he did not sleep a wink, now he sleeps a lot, he got up last night and ate a little cereal, so I think he is getting better, all I hope is that once he is completely clean he won’t ever use drugs again after all that he went through but of course I might be kidding myself, but we have done so much for years to help him and throwing money out the window on these stupid other drugs to get him off of one drug is crazy, it cost us over $100.00 each month on stupid subuxone, I just can’t afford it anymore and he definitely can’t since he is 21 and really doesn’t like to work or much of anything except play, so I hope this is a wake up call for him, because the money bank is closing. I hope everyone gets off of this subuxone once and for all, the doctors just string you along like it is the answer, but do you realize you have to get off of it one day and no matter how small of a dose they give you, you are going through withdrawals anyway, my son was already down to a quarter of a 8 mg pill, we just broke those things into 4ths, so he was basically doing 2 mg, just prolonging the agony. Good luck all!!!!

  3. “The plasma half-life of buprenorphine is 2-5 hours, but the elimination half life is over 30 hours. The volume of distribution of the drug increases with dose because of dose-dependent protein binding. Finally, the ceiling effect creates a non-linear relationship between blood level and pharmacologic effect. The practical result of these factors is that larger doses of buprenorphine produce opioid effects that last longer than smaller doses. A typical buprenorphine pain dose of 50-100 micrograms lasts for 6-8 hours, but in the super high doses used for addiction (8 mg equals 8000 micrograms), the opioid effects last much longer- allowing for once per day dosing.”

    Based on these facts should one expect that a person who has reduced daily dose (and stabilized) to say .4 mg (2mg strip lasting 5 or so days) anticipate a more abbreviated and less intense withdrawal period than a person going cold turkey from a larger, normal prescribed maintenance dose? And if that was the case wouldn’t the goal then for persons who are set on abstaining from Suboxone be to get stabilized to the lowest dose manageable prior to jumping ship?

  4. The ultimate factor in determining intensity of withdrawal is tolerance level. The different effective half lives of larger vs lower doses of buprenorphine is a factor in the length of withdrawal, but not a major factor. I say that because comparing half-lives may shorten or lengthen withdrawal by a couple days, but the total length of opioid withdrawal– about 8 weeks– makes those two days insignificant. As for your question, yes— jumping from the lowest possible blood level would reduce withdrawal. But there are other factors; some people just can’t maintain motivation long enough to taper down to very low levels, and might do better by jumping off at a higher level– which would be more painful, but would be less drawn out.

  5. Thanks Doc, I have had to reread the response several times but I think I probably have the gist of it. When you say “tolerance level” that would be the amount of the drug required to be effective – or – is it the max amount of the drug a person can tolerate?
    And in the final comment are you saying it would be less drawn out due to the discomfort associated while tapering to such a low level or are you saying a person stabilized at a lower level will require more withdrawal time from jump to fully withdrawn than a person jumping at a higher level?
    Sorry if the questions sound stupid. I’m not afraid to state that I do not fully understand the science of all this..

  6. By tolerance level, I’m referring to the amount of opioid that it takes to make a certain person feel ‘neutral’. If you took 100 mg of methadone for a month, your tolerance level would be equal to 100 mg of methadone, for example. The distance between that level, and feeling neutral off all opioids, is the amount of withdrawal that awaits you. If the person drops to 50 mg of methadone, there would be weeks of withdrawal, but eventually tolerance would drop to that level. Stopping all opioids would eventually result in a zero tolerance. It doesn’t mean you wouldn’t tolerate opioids– it means that at no opioids you feel normal. The second part of your question— the first is what I meant, i.e. it wouldn’t be drawn out by all of that tapering work. People sometimes get stuck doing tapers that never seem to go anywhere– but the person is constantly miserable, and constantly disappointed in himself for ‘failing’ over and over.

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