Step 7: Tapering

An Approach to Tapering

Most people in recovery eventually want to taper off buprenorphine. It is usually toward the bottom of their list of “to-do” life issues, so it comes months or perhaps even years after stabilizing in a recovery program. It generally remains higher on the provider’s to-do list than the patient’s. But it usually is on both of their agendas, a shared goal.

It should be emphasized that the desire to taper comes from the patient, not from the provider. For both patient and provider, real recovery involves other life changes first, and tapering happens only if patients have made gains in other areas of their life first: ridding oneself of user friends, maintaining stable relationships at work and at home; getting promoted; getting educated. And then, at some point most patients one day walk into the room and state that they are ready to taper.

They do not want to experience withdrawal symptoms, so the slower the tapering the better, and they want to feel they are in control of the process. Sobriety most of all requires a willingness and desire to change, which comes from within, after felt gains from previous changes. Change is not comfortable or pleasant, but it can lead to huge personal rewards. If it is coming from the patient, the motivation to continue, the felt progress, builds.

As the dose gets lower (toward or under 2mg per day of buprenorphine), the harder part of tapering becomes the mental part, the loosening of old habits and rituals, the fear of the unknown, the anxiety of being without their stable and always ready “friend.” There is no truth to the idea that “the longer you take it, the harder it is to stop,” except that old habits die hard. Detours often occur; patients will stabilize at a certain dose for months before resuming a taper. The goal is to stay in the game, hour after hour (after hour). Moral support and wisdom help. Slow and steady is the rule. If stress or drama intervenes it is often best to interrupt tapering and keep the dose steady until life issues are resolved.

Below are some positive indicators that a patient may be getting ready to taper, when it can help to ask in a nonjudgmental way if they can imagine or have ever thought of coming down on their dose. The more of these items are present, the better the chance of success:

  • Taking buprenorphine regularly, once or at most twice per day, and not in response to depression, fatigue, emptiness, insomnia, or urge.
  • Having month after month with no extra calls reporting lost or stolen buprenorphine, no “very bad weeks” where everything went wrong and forcing the need to “take a little extra.”
  • No use of intoxicants (alcohol, marijuana) and no issues with ongoing depression or anxiety needing medication—i.e. the ability to ‘live life on life’s terms.’
  • Stable job, stable finances, stable relationships, and preferably one or two hobbies or ‘passions.’
  • Complete loss of user contacts, and no immediate access to opioids (no spouse on pain or anxiety pills, no dealer calling every few days, etc).
  • No chronic pain, or acceptance that one will have to tolerate one’s pain.
  • Being on a regular exercise schedule.
  • Fear of relapse.
  • Age over 30. Age brings wisdom, persistence of intent, insight into emotions, and the realization that life is temporary and precious.

The best strategy in starting to taper is to move slowly, stay stable, avoid drama. At higher daily doses (16mg down to 2mg), buprenorphine’s long half-life can be taken advantage of, since physical withdrawal symptoms will not begin until more than 48 hours after the last dose. For example, lowering a single day’s dose by 2mg one day per week, though possibly anxiety-provoking, will hardly be noticed physically. If a patient is taking 8mg daily and says she wants to taper but is worried, suggest she try to take 6mg one day in the next day or two, 8mg the other days, and report back a week later with 2mg left over to see how it went, remaining (except for that one day) on her 8mg dose. Uniformly, patients are pleasantly surprised by how easy that was. Then, rewarded, patients can progress by dropping another 2mg on widely separated days, with no untoward effects, reinforced by the progress they are making.

Below buprenorphine’s “ceiling dose” of about 2mg per day, its half-life will be shorter, and for most people this will bring on withdrawal symptoms sooner. Taking the same dose but split into several doses a day is one strategy that often works (avoid taking it more than four times a day because dosing itself can become a fixation). Films can be cut with a razor blade or hobby-knife down to very small doses. Printable cutting guides are available on the internet. Cut two mg strips into 0.25, 0.12, 0.06, 0.03 and 0.015mg squares and put them in separate baggies.

Everyone is different, but here are some guidelines:

  • Above 16mg: decrease daily dose by 2-4 mg per month
  • 16 to 8mg: decrease daily dose by 2mg per month (= 4 months)
  • 8 to 2mg: decrease daily dose by 1mg per month (= 6 months)
  • 2 to 1mg: decrease daily dose by 0.5mg per month (= 2 months)

Below 1-2mg the approach needs to be individualized. Some people prefer to hang out at 1mg or 2mg for months or even years before they feel ready to “jump off.”

“Jumping off”

The lower the dose below 2mg, the easier it is to jump, but the harder it is to maintain that low dose while getting ready to jump, because of the unsaturated receptor sites. Everyone is different, but usually, somewhere between 1mg and 0.25mg per day, people who are motivated to get off the drug and who feel their life is stable and supported, can successfully decide to stop.

Withdrawal symptoms usually peak around 48 to 72 hours after the last dose. This will be the hardest time, but it does not get rapidly better after that. If possible, people should plan for 10 to 14 days off work and other stressful activities, or some support person present for this time and a way to stay busy – whatever seems right to the patient. Work or school can help keep one’s mind off the craving but it is important to anticipate the strong negative feelings that will occur while jumping off.  People feel unmotivated and exhausted after a few hours of work, easily overwhelmed and even depressed, for a month or more, as they adjust to their new sobriety.

Most people begin to emerge into a new sober life as the weeks progress. Sleep will slowly get better, mood will rise, and they will begin to feel again the full power of their feelings — happiness and discontent. This is when having other reasons to keep going, other pursuits, endeavors, passions to give one’s life meaning, becomes most important.

What patients can do:

  • It is difficult if not impossible to quit on one’s own, and it helps to feel there is a “support team,” so coordinate the plan with all concerned. The provider should be on the team, and notify one or two reliable friends or family members to be on “standby.”
  • Avoid caffeine. Moderation is always a good rule, so limit caffeine intake to maybe 2 drinks or cups per day, and those before 3pm.
  • Eat regularly and consume a healthy diet. Your body is having a hard time now, and needs you to feed it good healthy food! Vitamins C and B6 supplements might also help.
  • Exercise every day. Exercise works as an antidepressant, helps you feel good about yourself, and is good for you. Maybe all of those things are the same, (or maybe they aren’t), but exercise works.

What providers can do:

Being available, being perceived as “part of the support team,” is most important. This is a joint effort, and you are a trusted colleague. In addition, there are specific medications that can help specific symptoms:

Cholinergic Overload

  • Clonidine 0.1 mg   #18

1 tablet three times daily for three days, then 1 tablet twice daily for three days, then 1 tablet once daily for three days, then stop

**Dispense in 3-day supplies, hold if BP < 90/60**

Nausea/Vomiting/Insomnia

Default:

  • Diphenhydramine 25 mg   #36

1 to 2 capsules every 4 to 6 hours as needed (max 6 doses/day)

Alternate:

  • Promethazine 25 mg   #12

1 tablet every 4 to 6 hours as needed (max 4 doses/day)

or

  • Hydroxyzine pamoate 50 mg   #18

1 capsule every 4 to 6 hours as needed (max 6 doses/day)

Diarrhea

Default:

  • Loperamide 2 mg   #24

2 tablets first dose, then 1 tablet after every loose stool (max 8 tabs/day)

Alternate:

  • Bismuth subsalicylate 262 mg   #48

2 tablets every 30 to 60 minutes as needed (max 8 doses/day)

Muscle Spasms/Twitching

Default:

  • Cyclobenzaprine 10 mg   #6

½ (one-half) tablet every 8 hours as needed (max 3 doses/day)

Alternate:

  • Baclofen 5 mg   #9

1 tablet every 8 hours as needed (max 3 doses/day)

Aches

Default:

  • Acetaminophen 325 mg   #24

2 tablets every 4 to 6 hours as needed (max 4 doses/day)

Alternate/Add-On:

  • Ibuprofen 400 mg   #18

1 tablet every 4 to 6 hours as needed (max 6 doses/day)