You can get off of buprenorphine when the time is right without having to experience withdrawal. We’ve developed a tapering protocol five years ago that we have perfected I made available to all stable patients desirous of discontinuing buprenorphine. Understand, that a percentage of people who are addicted to opiates Will be better served with Long term maintenance with medication assisted therapy. However, after adequate counseling and implementation of appropriate lifestyle changes: e.g. stable job, stable home environment, stable relationships and the removal of triggers that lead to relapse - our protocol allows motivated patients to be free of ongoing treatment.
Three basic concepts must be understood to implement our protocol. Firstly, buprenorphine is a long acting drug. Secondly, the brain thinks in percentages and not milligrams. Thirdly, buprenorphine is a very potent drug and (in my opinion) should be dosed in micrograms and not milligrams. It is not possible to explain the entire protocol in less than 700 words. However, I will explain each of the three basic tenets.
The half-life of buprenorphine is at least 36 hours. The therapeutic effect therefore there’s at least 24 hours. Once a day dosing facilitates tapering much more easily than split dosing multiple times per day. Therefore, one basic goal before tapering should be to stabilize on once a day dosing. The long duration of action of the drug allows for alternating daily dosing such that the brain sees the average of the alternating doses. After a period of at least two weeks of alternating doses it is usually easy to transition to the lower dose every day as the next step and reducing the amount of medication taken per day.
The second and third concepts are illustrated by the fact that when used for pain in opiate naïve patients, buprenorphine is dosed in 25 to 75 µg (That’s MICROgram) dosages. The lowest dose form available for treatment of opiate dependency in proprietary products is 2000 µg or 2 mg. Therefore, to reduce the daily dose by smaller percentages it is necessary to use compounded buprenorphine. Reducing one’s dose from 16 mg per day to 8 mg per day is a 50% reduction in dose. This is usually not well-tolerated. Similarly, reducing the dose from 4 mg to 2 mg or from 2 mg to 1 mg is similarly not well-tolerated. Most patient will tolerate a reduction in their dose on a per day basis of up to 15 to 25%, without experiencing significant withdrawal symptoms. The exact schedule for tapering must be individualized and is beyond the scope of this article. Suffice it to say here that patients should be tapered down to between 0.3 and 0.5 mg per day before initiating a protocol of strategic skipping of days as part of the tapering effort.
This protocol ironically works best when closely supervised buy a knowledgeable physician monitoring for subtle signs of withdrawal. Clinical evaluation will show when a patient has tolerated a reduction in does to a given level. Because addicts have frequently experienced severe withdrawal in the past, sometimes in their zeal to get off medication, they minimize minor signs and symptoms of withdrawal. When present, sometimes it is better to remain at a given level of dosing for an extra couple of weeks before further tapering. When no signs of withdrawal are present it is predictable when a patient will tolerate aggressive further tapering. Patients can be taught how to make as many as two or three adjustments in their dose between monthly visits. Good communication and documentation facilitates adjustment in subsequent prescribed or proprietary or compounded dose forms of the medication when appropriate. Patients interested and learning more about this protocol can schedule a consultation at 770-559-9554.
** A detailed explanation of this protocol is available for prescribing physicians via email: drlocke@wisemedicalcenter.com.