Posts Tagged ‘taper off buprenorphine’

Tapering Off Suboxone: Three Patients’ Success Stories

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

This year I’ve had three long-term patients taper off the buprenorphine products I was prescribing. All three are doing well and are happy with their treatment outcome. Since tapering off buprenorphine products can be challenging, I thought I’d share their stories, to help other people who wish to taper off buprenorphine. (Note that when I say buprenorphine, I mean to include all the brands and generics: Suboxone, Zubsolv, Bunavail, generic combination product buprenorphine/naloxone and the generic monoproduct buprenorphine.)

The first patient had been on buprenorphine for over ten years. She saw one of the first physicians to prescribe buprenorphine, and I inherited her from this prescriber after he retired.

When she started Suboxone, which at that time were only available in tablet form, she stabilized at eight milligrams. She stayed on that dose for about four years. She saw her prescriber monthly for the first year and a half, then every other month. By the time she started seeing me, she had cut her dose to 4mg per day without too much difficulty. When the suboxone films were available, we switched to those, both because that’s what her insurance would pay for and because I thought she could taper more easily with films.

Over the first year with me, she brought her dose down to 2mg per day, reducing by a half milligram every three or four months. I then switched her to the 2mg films, and she continued to cut off more and more from her films. I gave her some guidance, but she largely managed her taper on her own.

After a year or two, she asked me to prescribe only fifteen films per month, since she was taking half of a film per day. A year later, she had dropped to only a forth of a film per day, and needed only eight films per month. This slowly progressed until she had brought her dose down to one-sixteenth of a two milligram film which she took every other day.

That’s right…she was taking .125milligrams every other day. Her urine drug screen still showed positive for buprenorphine at her visits. I told her I thought she could stop taking that dose and not have any withdrawal symptoms, but she told me she still felt withdrawal if she missed her every other day dose. I didn’t push her; I didn’t mind prescribing only one 2milligram film per month!

She continued at this dose for over a year. When she missed a visit earlier this year, I asked my staff to call her. Sure enough, she forgot to take her dose for several days, and didn’t feel any withdrawal. I offered to see her one more time, to talk about relapse prevention and options to give her insurance against a relapse (Vivitrol), but she didn’t want another visit. I congratulated her and told her if she had questions or problems in the future to call us.

During her last year or so, we talked regularly about relapse prevention. We made plans for what to do if she had a catastrophic medical problem that required pain medication (broken bone, surgery, etc.). We discussed other big relapse triggers, such as strong negative emotions, and being around people who had opioids or other drugs.

This patient was very involved with 12-step recovery. Even after so many years of recovery, she went to three or more meetings per week. She had a sponsor and served as a sponsor to newer members. She had relatives in 12-step programs, and most of her friends were members of 12-step recovery groups.

The second patient also tapered her dose over years. I knew her for around fifteen years, first as a patient at an opioid treatment program, where she dosed on methadone. She did well from the start, though she had some slips with non-opioid illicit drugs.

She didn’t care for the restrictive nature of the opioid treatment program, so when she’d been doing well there for several years, I told her about the new option of buprenorphine treatment through an office setting. She decided that was what she wanted to do, and proceeded to taper her methadone dose, slowly.

Once she was down to 30mg, which took about six months, she made an appointment with an office-based physician, who started her at suboxone 16mg per day. When that physician retired less than a year after she started Suboxone, she transferred to my office-based program.

By the time she transferred to my office-based program, she was down to 12mg per day. Just like the first patient, she steadily tapered her own dose. She reduced her dose by an estimated milligram of Suboxone every four months.

I say estimated because cutting the Suboxone films is largely guesswork, and the manufacturer says there are no studies to show buprenorphine is evenly distributed over the film. While that’s true, buprenorphine is so long-acting that I wonder how much variation patients get in their blood levels, even with uneven distribution.

Just like with the first patient, we switched her to the 2mg film once she got to a 2mg per day dose. She continued to reduce on her own. She would cut her dose and wait for a month or two before going down again. I saw her only every two months, given her stability. She had negative drug screens, always kept her appointments, and lead a productive life. I gave her as much advice as I could, but I was impressed that she was able to listen to her body and taper only as fast as she was comfortable.

Once she was taking one-eighth of a 2 milligram film (.25mg), she stopped her medication. I saw her for one last planned visit, and we talked about how she felt. At that point, she’d been off buprenorphine for four weeks. She noticed aches and pains more intensely than in the past, but said it wasn’t anything ibuprofen or Tylenol couldn’t fix. It took a little longer to get to sleep, but she was still functioning well as a mother to her four children. She was ecstatic to be finished with medication-assisted treatment, and she knows that – heaven forbid – if she does relapse, to call quickly and come to see me to get back on buprenorphine.

Again, we had been discussing relapse triggers for months. We also discussed naltrexone, available as a once monthly shot called Vivitrol, as insurance against a relapse but she decided against it. She felt she didn’t need it.

She did individual counseling while she was a patient at the opioid treatment program, but hasn’t done much counseling recently. She saw a therapist many years ago, after a traumatic life event, but didn’t feel she needed to continue with this. She tried 12-step recovery but didn’t feel it was right for her.

Initially I worried she wouldn’t make progress in her recovery without continuing to see a therapist, but when I saw how well she was functioning in life, I decided not to push the issue. The only counseling she got was with me, during our 20-minute office visits. I’m not a trained therapist, but I like to think I have developed some skills over the years.

Her life changed completely over the past ten or so years she’s been on medication-assisted treatment. Early on, she let go of drug-using friends and acquaintances. She became focused on what was important to her: her young family and her extended family. She got a part-time job after her youngest child started school, to afford some extras for the family. Her husband is in his final stages of taper from buprenorphine, and she hasn’t rushed him, letting him take his own time, just like she did.

Drug use holds no allure for her; she hasn’t had any cravings or desires for any sort of drugs for years.

My third patient to taper off this year just saw me several weeks ago. It’s been over eight years since she used any illicit drugs. At her last visit, she declared this to be her last visit, saying her last buprenorphine had been taken six weeks prior, and that she felt fine.

She has been at a dose of less than 8mg for about two years, and less than 2mg per day for at least the last eight months. She tapered on the generic combination tablets, buprenorphine/naloxone 2/.5mg, cutting them into quarters. Once she got to one-quarter per day (.5mg), she took one of these quarters every other day for several weeks and then stopped completely.

Again, we’ve been discussing relapse prevention for literally years. Again, she decided against starting naltrexone as a safety net against relapse, feeling she didn’t need this medication. She was happy and smiling and was very kind when she thanked me for helping her these past years. I told her it was truly my pleasure, and I was honored to be even a small part of her success.

These three patients have common themes in their successes. All three had very support families who didn’t rush them to get off buprenorphine or shame them from being on it. I also didn’t pressure them. I said I’ll do everything I can do to help you taper off this medication, but there’s nothing wrong with staying on it either, if that’s what you prefer.

This left the decision in their hands. All three said this was important, since they had control over when/if/how they tapered. Once I told one of these patients to listen to her body, since she was the expert on her body and how it felt. This resonated with her, and she thanked me for saying that. She felt that took the pressure from her to try to meet someone else’s expectations.

These three patients all tapered their dose very gradually, over periods of not days or weeks, but months and years. While such slow tapers can be frustrating, not to mention expensive, to people who want a quicker exit off medication, maybe slow tapers allow the body more time to adjust to changes in dosage.

Two of the three patients exercise regularly at a gym. The third is also active, and walks nearly daily. Exercise usually helps us to feel better, both physically and emotionally. I wonder if exercise also boosts endorphin, our body’s own opioid. I’ve started recommended patients start a reasonable exercise program in advance of starting a dose taper.

All three of these patients have faced serious adversity in the past and survived it. This tells me they have skills they can use in their recovery. All three had tremendous resolve to do what was necessary to get their lives back. They kept at it, accepted the few setbacks that came their way as part of the process, and kept moving forward, even though progress was slow at times.

I admire all these patients. All have excellent prognosis, and we’ve talked about how opioid use disorder is a chronic illness. They need to be on guard against relapses the rest of their lives, and if relapse happens, I think they will know what to do.

I have another crop of patients who are dosing at 4mg or less of buprenorphine per day, all in the process of tapering. I’ll update my blog with those stories after they taper.