A Letter to My Patients: The Truth About Stopping Suboxone

​To My Patients:
​
Medication-Assisted Treatment (MAT) using Suboxone (buprenorphine/naloxone) is often the first step in reclaiming your life. It gives you a break from the chaos of opioid addiction, removes the physical cravings, and allows you to feel normal again. It gives you the stability to be the parent, the spouse, and the child you haven't been able to be for a long time.

While Suboxone is a miracle for stabilization, many patients eventually ask: "How do I get off this medication?"

Addiction is a chronic disease. No one wakes up one morning and decides to become an addict. It is a trap where you lose the trust of your family and the respect of yourself. Suboxone stops the bleeding, but it does not heal the wound. Once the drugs are gone, the real work begins. You must fill the void that caused the addiction in the first place through counseling, 12-step programs, and lifestyle changes.

The Philosophy of Weaning

I tell all my patients: Ideally, you should remain on Suboxone for at least long enough to turn your life around and find some level of recovery. For most this is at least one year. You need to at the very least change people, places and things. If you accomplish this, it naturally follows to  end having the consequences of addiction. You will also improve life's situation like securing employment,  being able to pay your bills and repair relationships. Once you are stable, we can discuss weaning (tapering).

I encourage weaning to my patients, but I do not require it. There are several issues we need to address in preparation for weaning with many patients.

Some family and friends may tell you that "taking Suboxone is trading one addiction for another." Others may say you are using a "crutch" or that "people taking suboxone are not really clean." I disagree strongly. While using Suboxone you are under a doctors care, treating a deadly medical condition, with a life saving medication. Your life usually has changed so much for the better after a year of Suboxone that is hard to describe to someone who does not understand addiction.

As we begin discussing the idea of weaning some began to get nervous. Many patients are afraid of what their life would be like without Suboxone. They worry about not having something to make them feel okay. It's something they have trouble putting into words, but is there. I almost always bring in discussion up for them.

They also have a fear of the return of cravings or withdrawal symptoms. And while I assure them this will not happen and we have a way to deal with it if it did occur, these fears are real. It seems easier for those who participated in counselling or recovery to overcome these fears. But most do eventually.

Dependence on Suboxone is real, and stopping abruptly is not an option. Quitting "cold turkey" almost always results in weeks of withdrawal, dysphoria, extreme fatigue, insomnia, or even relapse. At first you likely wouldn't feel actual physical withdrawal symptoms until the beginning of day 3. But your mind would start to panic within 12-18 hours. This is the mental obsession of addiction, called a "Craving." It is anxiety on steroids. You can not think of anything else. Then as the withdrawal starts to kick in you have the worst case of the "Blahs" you can imagine. You can not sleep no matter how tired you  feel. It is miserable.

One of the only successful ways to stop taking Suboxone is to wean very slowly. The goal is to decrease your dose so gradually that your body never realizes it is happening, and thus you do not have any withdrawal. Before you are ready to taper your dose, you must get your mind right. Meaning you have to want to do it more than you want to keep taking Suboxone.
​
The "Weaning" Method

Over my years of practice, I have developed a method that I have found to be successful for patients ready to taper. I tell my patients who are reluctant "To just try it." Then I tell them "If you don't like it or if your miserable you do not have to keep doing it." The

1. The "Test" Phase:

• Cut a tiny, almost invisible piece (approx. 0.13mg) off your strip or tablet. Cut it 1/2 about 5 or 6 times.
• Throw the small piece away. Don't save it because you may obsess about it all day.
• Take the rest of your dose as normal.

Do this for a month or so. Your body will not notice the missing 0.13mg, but your mind might obsess over it some, at first. Throwing it away breaks the mental attachment. Almost all my patients come back and say, "I can't believe how easy that was."

2. The Reduction Phase Once you realize you can survive on slightly less, we begin the true taper.

Decrease your dose by roughly 1/16th to 1/8th (0.25mg to 0.5mg) every week.

• Make your reduction on say, a Saturday. This gives you Sunday to see how you feel before the work week begins.
• If you feel okay, then pre-cut your doses for the entire week on Sunday. If you don't prepare, life will get in the way, and you can easily slip back to your full dose before long.

3. What If I Feel Bad If you drop your dose one weekend and feel unwell, go back to the last dose where you felt good. Then you wait a week, and try again. There is no shame in pausing. Progress not perfection. Some people need to taper more slowly. I tell them it is alright to cut your dose less or wait 2 weeks. I also say "when you come back for your next appointment you do not have to be at a certain dose." I do not want people to feel shame because they did not do enough.

4. When You Get To 2-4 mg: When your dose gets lower, you will reach a point where you have to slow down. Then wait 2 or sometimes even 3 weeks before dropping dose.

5. Random "Not-Rules":

• Also do not taper during stressful times, such as holidays or family crises.
• I always tell people to take a couple weeks off around Christmas.
• Almost everyone reaches a point where it is going so well they think, "I will go faster and cut my dose by 4 mg, even though Dr Westcott told me not to." They come back and tell me it was terrible. "Don't go to fast."

The Final Step: The "Freedom Day"

As we continue, we will eventually reach a very low dose (0.25mg or 0.5mg). Once you are stable at this micro-dose for a few weeks, we are ready for the big stop day

The Naltrexone Protocol: Naltrexone will be given as a one time dose. This effectively knocks all of the Suboxone off your receptors in your brain. 

What to expect:

• 1. You will likely experience one day of mild withdrawal. Some say they do not have any withdrawal. Rarely the withdrawal is uncomfortable for 24  hours.​
• 2. This is followed by one day of fatigue.
• 3. The third day, most patients feel normal.

Comfort Meds:

• ​I provide medications to manage anxiety and insomnia during these 48 hours. I recommend they take a sleep aid for a month or two.
• This avoids the 3–4 weeks of "the blahs" and low energy that usually accompany stopping Suboxone. It creates a clean break.

Moving Forward

Whether you stay on maintenance or choose to taper, the goal is freedom. If you are ready to start this process, we will do it at your pace, ensuring you remain safe, comfortable, and sober.

​I hope this helps.

Dr. Robert Westcott, MD, FASAM