How to Taper Off Suboxone and Make It a Success Story

# How to Taper Off Suboxone and Make It a Success Story

How do you taper off of Suboxone without getting sick or going back to opioids?

If you search for a Suboxone taper schedule, you will find plenty of them. Many promise to get you off of buprenorphine in a week or two, with a chart of doses and a few tips about hot baths and electrolytes. Some readers have already tried one, felt terrible by day four, and gone back to the full dose, or worse.

While some of those plans come from people who mean well, the problem with them is not the hot baths. It is the speed. Buprenorphine leaves the opioid receptor slowly, and the body needs weeks, not days, to settle into each lower dose. A taper that drops the dose every day is a slow-motion cold turkey.

When I say Suboxone here, I mean it the way patients say it, as the name for all of the buprenorphine medications used to treat opioid dependence, films, tablets, and generics alike. Over the years I have watched patients taper off of buprenorphine well, and I have watched others try to rush it. The difference between the two groups is rarely willpower.

So, what does a successful Suboxone taper look like? It is slow, it is patient-directed, and it takes the last milligram more seriously than the first eight.

Suboxone did not put you at the top of the building.

The most common complaint I hear about Suboxone is that the withdrawal is worse than heroin withdrawal, and that the patient wishes they had never started. Did the medication create a new dependence problem on top of the old one? This is a good question, and there is an analogy that helps.

Imagine that you are standing on the roof of a tall building that has an up elevator and no stairs. The height of the building is your level of physical dependence on opioids, and every month of use took you up another floor. You could jump, and some people do. Unfortunately, landing is hard, and most jumpers regret the leap.

Now, imagine that the fire department arrives with the only equipment they have, a long ramp. As you walk down it, slowly and safely, you may forget the elevator ride that took you up. Somewhere around the tenth floor, you start to blame the ramp for how high up you are.

While this is not a perfect analogy, it makes the point. The ramp did not get you where you are. It is simply the safest and least painful way down, and a person who blames the ramp is likely to jump off of it halfway.

Being dependent on Suboxone is not the same as being addicted to it.

Physical dependence is not addiction. Dependence means that the body has adapted to a drug and reacts when the drug is reduced too quickly. Addiction is a pattern of craving, compulsion, and continued use in spite of harm.

While buprenorphine causes dependence in everyone who takes it long enough, addiction to it is rare, because it holds on to the receptor and does not deliver the highs and crashes that drive addictive use. In fact, most patients describe the opposite of addiction on Suboxone. The obsession fades, the cravings go quiet, and they stop thinking about opioids for most of the day.

Unfortunately, many people, including doctors, confuse the two. A patient who needs a slow, supervised taper is told they are “addicted to Suboxone” and sent to a “Suboxone detox” or a rehab, where the length of the taper is set by the length of the insurance stay. Rehabs are glad to sell a thirty-day program to a person who needed a six-month taper.

What that person needed was a doctor with time and a plan. Dependence is treated with a taper, not with a program.

Whose decision is it to taper?

Yours.

The plan to reduce or stop Suboxone should be patient-initiated, and it should be your idea before it is anyone else’s. If you are comfortable on your medication and doing well, there may be no reason to change anything, and some patients do best staying on buprenorphine for many years.

I have seen patients relapse because they stopped their Suboxone too soon, and when I ask why, the answer is almost never a medical one. It is a family member, a friend, a trusted “expert,” or a stranger with an opinion and a plan that sounded reasonable at the time. In one pattern that repeats, a sponsor with many years in the program told a sponsee that they were not really in recovery until they were off of their medication.

While twelve-step fellowships help a great many people, and I would not discourage anyone from working the steps, your medical treatment is between you and your doctor. In the language of those programs, it is an outside issue, and a member who tells you to quit your prescription is speaking for themselves, not for the program. They are also not the one who will take the risk.

It is nobody’s business how you take prescribed medication. If someone close to you has a plan for your taper, bring the plan to your doctor. If it is a family member, bring them to the visit, give consent for them to be in the room, and let them hear the reasoning. Whatever you do, do not plan a taper in secret.

Tapering too early or too fast can be deadly.

When a Suboxone taper happens too early in treatment or too fast, the usual result is not a drug-free life. It is a relapse. Cravings return, the patient goes back to heroin, fentanyl, or pills, and the tolerance that once protected them is gone.

This is where the overdose deaths happen. A person who used a certain amount of fentanyl a year ago cannot safely use that amount today. In fact, the prescribing information for Suboxone tells doctors to advise patients that they may relapse after stopping, and, because a relapse puts the patient at risk of overdose, to strongly consider prescribing an overdose reversal drug, which in practice means naloxone.

I agree with the label. Every patient tapering off of buprenorphine should have naloxone at home, and the people around them should know where it is. While the people pushing you to quit usually mean well, tell them that if the push leads to a relapse, they had a part in what follows. That is not a threat. It is how these stories usually end.

If you or someone near you has taken an opioid and is not breathing normally or cannot be woken, give naloxone if you have it and call 911. Do not wait to see whether it passes.

Why do people want off of Suboxone fast?

The reasons are understandable. Some patients have side effects, most often constipation, sweating, headache, insomnia, or tiredness, and they assume the only cure is to stop. Others simply want to move on with their lives and be done with pharmacies, prescriptions, and monthly visits.

And, some want to join a fellowship that frowns on medication, or they are tired of hiding the medication from people who do. While every one of those reasons is real, none of them is a reason to go fast.

Side effects deserve their own conversation before a taper begins. Many are dose-related and ease with a modest, slow reduction, and fatigue on Suboxone in particular often has a cause other than the buprenorphine. In my experience, in rare cases the naloxone in the film is the culprit, and a switch to a buprenorphine-only tablet, the generic of the product once sold as Subutex, may be the answer.

After a year or more of stable treatment, a slow, patient-paced taper with support, and when needed a short course of comfort medication, is what ends in success. A fast taper mostly ends in withdrawal and a return to use. Speed is the wrong thing to fix.

Why does the last milligram feel bigger than the first eight?

This is the part that most online taper charts get wrong. Buprenorphine occupies opioid receptors in a way that is not proportional to the dose. At the usual treatment doses, most of the receptors are already occupied, so a cut at the top of the range may change the occupancy surprisingly little, and patients often barely notice it.

At the bottom of the taper, the picture flips. A cut of the same size near the lowest doses removes a far larger share of the remaining receptor occupancy, and the jump from a small final dose to zero is the steepest reduction of the entire taper. So, a chart that drops the same amount every week feels easy in the first month and brutal in the last.

The answer is to make the reductions shrink as the dose shrinks, in proportion rather than in fixed amounts, and to hold each new dose for weeks until you feel stable. This pattern is called a hyperbolic taper, and it is the same logic behind the benzodiazepine and antidepressant tapers I do every week. While the shape of the curve is the same for everyone, the steps are not something to copy from an article. They belong to you and your doctor.

For years I observed that patients got sick at the last step no matter how low their final dose was, and for years I explained it with recovery slogans about the “jump off.” Receptor occupancy explains it better, and it explains what happens when you quit Suboxone cold turkey. When the final dose is very small, arrived at gradually, and watched by the doctor before, during, and after, the ending is often uneventful. Skip those steps and it is not.

How can you take a dose that no manufacturer makes?

Suboxone films and tablets come in a handful of strengths, and the smallest Suboxone strength holds 2 mg of buprenorphine. What happens when the right next step is a dose between the manufactured strengths, or well below the smallest one? Cutting a film into quarters with a razor blade is imprecise, and many patients say that sitting at the kitchen table cutting up their medication feels too much like the old days of active use.

Compounded buprenorphine solves both problems. A compounding pharmacist can prepare buprenorphine, with or without naloxone, at the exact strength your stage of the taper calls for, including strengths far smaller than anything a manufacturer sells. At the low end, a liquid preparation lets the dose come down in steps that would be impossible with a film. For tapering, the future of pharmacy has been sitting on the compounding pharmacy’s shelf for years.

Yet, not every prescriber knows to ask, and not every pharmacy prepares it. The question is worth raising at your next visit, and if your doctor cannot arrange it, that is a reason to look for one who can.

What are Suboxone withdrawal symptoms like, and how long do they last?

Suboxone withdrawal is real, and it looks like other opioid withdrawal because buprenorphine is an opioid. Sweating, chills, gooseflesh, yawning, a runny nose, stomach cramps, diarrhea, muscle aches, restless legs, insomnia, anxiety, and low mood are the usual symptoms. Cravings can come along with them.

There are two differences. The Suboxone prescribing information describes the withdrawal syndrome as typically milder than withdrawal from a full agonist, and possibly delayed in onset. Heroin, fentanyl, and oxycodone are full agonists. In my experience, that delay is why people misjudge it. They feel fine for a day or two after a stopped dose, decide it will be easy, and then get sick, and because the drug leaves slowly, the discomfort runs longer than a short-acting opioid’s would.

In my experience, after a stopped full dose the worst of it comes in the first week or two, and a tail of poor sleep and low energy can run for weeks after that. No one can promise a schedule.

While some patients say it felt worse than heroin withdrawal, I believe the reason is usually that they stopped from a full dose, or dropped too far at once, rather than that buprenorphine is the crueler drug. The same person, walking down the dose over months, usually reports something much smaller. Of course, I do not fully know why one patient barely notices a step that flattens another, and anyone who claims to predict it is guessing.

A taper changes the shape of withdrawal. Instead of one long illness, you may feel a few days of mild symptoms after each step down, which settle as your body catches up. If the symptoms do not settle, or if you notice a persistent craving for heroin or other opioids, that is information: the step was too big or too soon, and your doctor needs to hear about it. Most of the horror stories about quitting Suboxone come from tapers that were not tapers.

Can your doctor prescribe something for the symptoms during a taper?

Yes, within limits. While no medication erases opioid withdrawal, two prescription drugs take the edge off of the physical part. Lucemyra, or lofexidine, is a non-opioid medication that the FDA approved in 2018 for mitigation of opioid withdrawal symptoms, and its label allows a course of up to 14 days.

Clonidine is its older cousin, a blood pressure medication in the same family that has long been used for opioid withdrawal. Both can lower blood pressure and heart rate and cause drowsiness or dizziness, which is why they are short-term tools prescribed and watched by a physician. Lofexidine does not treat cravings or depression, whatever a website may claim, and its label calls for it to be stopped gradually rather than all at once. There is more about Lucemyra and Suboxone in an earlier article.

Fortunately, most patients need none of these. When the dose comes down slowly enough, the withdrawal that follows each step is mild enough to handle with time, sleep, and patience.

Is kratom a shortcut off of Suboxone?

No. While kratom is sold openly in much of the country without a prescription, and some people use it to get off of Suboxone or to treat withdrawal on their own, it is not a taper tool. Kratom’s two main active compounds act at the same mu opioid receptors as opioid drugs. No kratom product is an approved medication, so there is no label, no standard dose, and no one answerable for what is in the bag.

Yet, the receptor activity is the real problem. Kratom is used the way a short-acting opioid is used, dosed several times a day with a quick onset and a fade within hours, and in my experience that is exactly the pattern that stirs up cravings. Buprenorphine holds the receptor and quiets them.

The sequence is familiar. A patient switches from Suboxone to kratom to be “off medication,” the cravings come back within weeks, and the next step is fentanyl. Whatever kratom is, it is not a taper. It is a change of drug, to one with no label, no measured dose, and no track record.

What about naltrexone after the taper?

Naltrexone is a legitimate option for the time after Suboxone. It is a pure opioid blocker, not an opioid and not a controlled substance, and it comes as a daily generic tablet and as the monthly injection called Vivitrol. For a patient whose work forbids controlled substances, or who wants a safety net against relapse without staying on buprenorphine, it deserves a conversation.

While naltrexone is a safe long-term medication, the timing of the first dose is the safety issue, and it is the one thing the older version of this article left out. Naltrexone started while buprenorphine is still in the system precipitates withdrawal, an abrupt and severe version of the sickness you spent months avoiding. The Vivitrol prescribing information calls for a minimum of 7 to 10 days opioid-free before the first dose, and it warns that after buprenorphine or methadone the danger of precipitated withdrawal can last as long as two weeks.

So, the switch is not a matter of picking up a new prescription on the way home. It is a physician-managed transition, with the taper finished, a waiting period, and sometimes a test dose to be sure the opioids are gone. I compare naltrexone and Suboxone in more detail elsewhere. Whether the shot or the tablet fits you is something I can advise on in a consultation.

Who should be part of the plan?

Start with the prescriber. Since the end of 2022, when the special “X” waiver was eliminated, any prescriber whose DEA registration covers Schedule III drugs can prescribe buprenorphine, subject to state rules. That means more doctors can help, and also that more doctors are new at it. For a taper you want a doctor with time, patience, and an interest in the last milligram, not a pain clinic or a cannabis clinic where you are one of forty patients that afternoon.

The neglected hard part of buprenorphine treatment is finishing it. In fact, patients start treatment more willingly when they trust that the same doctor will help them end it comfortably, and a prescriber with no plan for the ending tends to have patients who never begin.

If you have a therapist, consider telling them your plans, and ask what they have noticed about your progress. A few close friends or family members who understand what you are doing help as well. None of this is a requirement, and no one gets a veto over your decision, but people who know what you are doing can catch a bad week before you do.

While you are planning, plan for the ordinary emergencies. What will you do if you need dental work? What if you need surgery? What if a friend offers you a pill on a bad day? Having those conversations with your doctor before the taper, not in the oral surgeon’s chair, is part of doing this right.

The doctor’s job is to keep you safe while you set the goal.

While your doctor understands the receptor chemistry and has watched many tapers succeed and fail, you know your life, your triggers, and how ready you are. A good Suboxone taper is a negotiation between those two kinds of knowledge, and it moves at the speed of the slower party.

If a step is too fast, the doctor must help you slow down. If the taper is going better than expected, the two of you may agree to go a bit faster, as tolerated. Symptoms along the way are not failure. They are the plan telling you to slow down.

Keep your appointments through the last dose and for a while afterward, because the weeks after the final dose are when cravings tend to come back. And, if it turns out that this is not your year to taper, staying on buprenorphine for another year, or for good, is a legitimate medical decision, not a failure of nerve.

In my practice, buprenorphine treatment and tapering are done by telemedicine for patients in Florida, with weekly video visits that leave time for the questions above, compounded low-dose buprenorphine when the taper calls for it, and the same physician staying through the ending. The taper is yours. The job of keeping it safe is mine.

To ask whether a patient-directed Suboxone taper is right for you, contact Dr. Leeds through the contact form.

This article is educational. It is not medical advice, and reading it does not create a doctor-patient relationship. Decisions about starting, continuing, or tapering any medication should be made with your own physician.