Tapering off Methadone or Buprenorphine (Suboxone): Pain and Relapse

Physical pain is a relapse trigger for recovering opioid addicts, especially after they’ve tapered off maintenance medications. While on maintenance medications, most patients can no longer get high from opioids, and so are less likely to take prescribed opioid medication in destructive ways. Once off maintenance medications, patients can again feel euphoria from opioids, even when taking opioid medications as prescribed. This can lead to medication misuse and eventual relapse back into active addiction.

Pain can be acute (think broken bones or a kidney stone), or more chronic and persistent, as in chronic back pain. Acute pain by definition resolves within a short time, and there are ways to reduce the risk of relapse for the relatively short time opioids are necessary. Before a patient on maintenance medications (methadone or Suboxone) even begins a taper, he should have a clear plan for handling an acutely painful event.

Here are some ideas:

  • Tell the prescribing physician that you’ve had problems with addiction to opioids in the past. Try to use a non-opioid pain medication if possible
  • If you have to take opioids, ask the doctor to prescribe fewer pills at a time, and have more frequent follow up visits, for more accountability
  • Have a dependable non-addict hold your pill bottle and dispense to you as prescribed.
  • Tell your circle of supporters, whether that’s friends, family, and/or your 12-step group members that you need to take pain pills, and could use extra support and accountability.
  • Read the booklet published by Narcotics Anonymous, “In Times of Illness”
  • Ask a dependable friend or family member to do daily pill counts for more accountability, if you don’t have someone that can hold your pill bottle

A patient with chronic pain obviously has a more complicated situation. Preferably, the recovering opioid addict can find some way to manage the chronic pain without opioids. If that’s possible, then the patient can slowly bring down their dose of methadone or buprenorphine, knowing that if pain returns, there’s a non-opioid way to managing it.

For a patient who can’t find an adequate non-opioid way to relieve chronic pain, staying on maintenance medications may be the best option. Methadone and buprenorphine (Suboxone) prevent opioid withdrawal symptoms for longer than 24 hours in most patients, which is why we use them to treat addiction. But the anti-pain effect wears off at about six hours after dosing. Therefore, methadone and buprenorphine may not be ideal for pain management, but may be enough to bring the patient’s pain to manageable levels. For this reason, a patient with both pain and addiction may reasonably decide to stay on maintenance medications. If such a patient does taper off maintenance medications, every flare of pain is a potential relapse trigger.

For more on management of pain on maintenance medications like Suboxone and methadone, please see my blog entry of 10/16/11.

3 responses to this post.

  1. Posted by ALEA on August 26, 2012 at 12:56 am

    my question is Ive been taking methadone since Nov, 2011. The clinic Im at now, I cant pay my balance untill my first paycheck so since I owe they are tapering me down from 100mgs by decreasing me 10mgs every other day! Im now at 45mg and feel awful but not as bad as I would if it was cold turkey. once I get down to like 30 or below how sick will I get and is this method dangerous for me and my baby who I been nursing for 4 months Now??????


    • If you’re otherwise healthy it’s not dangerous, but I think you will have significant withdrawal. Can your clinic or your other doctor provide you with a prescription for clonidine? It can help some of the withdrawal symptoms. There’s no danger to your baby, since there’s not enough methadone secreted in breast milk to influence the baby one way or another.
      Most clinics offer some sort of taper for financial reasons. It may differ from 4 days up to 21 days. It’s a shame such treatment can’t be covered somehow by health insurance. Perhaps in the future, with new changes in healthcare, everyone will have access to coverage that pays for OTP treatment, especially since it’s one of the most heavily evidenced-based treatments in all of medicine.


      • Posted by ALEA on August 26, 2012 at 6:15 am

        Well Im glad to know that. I feel bad but been able to function which is good cause I have 5 kids, just moved to a new city along with a new management posistion. So my life is going in the right direction but its going to be tough tapering off methadone so quik. Im really worried Im going to get very sick??? I live in the state of PA which luckly gave my children and I health care and In the state of PA, opiod treatment centers except my healthcare!!! But its gonna be a week or so till Im able to get into a new clinic. Anyway thanks for the helpful tips and any advice u have to give will certainly help. Thanks again 🙂

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