Re: Taper Off Suboxone: Using The Films
Wesley Dupler
The whole point of buprenorphine treatment is to suppress cravings and withdrawal so that you can make big changes in behavior, routine, living situation and thinking. It's these changes which, in effect, rewire the brain and reverse some of the craving-causing brain adaptations. If this is not done first the taper will likely be shortly followed by relapse.
Despite a lack of current evidence, there are also practical challenges to implementation of alternative initiation strategies for buprenorphine. Insurance coverage for off-label use may be a barrier to successful implementation of certain strategies [26]. Traditional initiation typically occurs in the outpatient setting, whereas many of the included cases describe inpatient initiation which has direct implications to resources and costs of care. In general, many of the alternative initiation methods require manipulation of prescription products to achieve small enough doses to be consistent with published protocols. For example, manipulation of buprenorphine/naloxone to execute a microdosing protocol requires using scissors, razors, or folding and ripping buprenorphine/naloxone films to achieve the desired dose [27]. In the outpatient setting, patients are left to manipulate the dosage forms themselves. In the inpatient setting, some institutions may choose not to operationalize these practices based on the available evidence or may have policies and procedures that prohibit certain strategies [28, 29].
Buprenorphine is a mu opioid receptor partial agonist that is indicated for pain management and the treatment of opioid use disorder (OUD). Traditional induction for patients with OUD requires a patient to experience opioid withdrawal (measured via COWS scores) prior to buprenorphine initiation. This is necessary in order to prevent the experience of precipitated withdrawal due to the partial agonist effects in the setting of a full opioid agonist when using high doses of buprenorphine (mg doses). Micro-dosing of buprenorphine uses the buprenorphine buccal films (Belbuca), which are dosed in micrograms, allowing for the induction of buprenorphine without the need to first experience withdrawal or the risk of precipitated withdrawal given the very small doses. Doses are increased over 3-4 days to achieve full maintenance dosing. Case reports and case series support this approach in hospital settings, and we have successfully completed buprenorphine induction using this approach in two patients at HUP.
"@context": " ", "@type": "FAQPage", "mainEntity": [ "@type": "Question", "name": "How long does it take to get off of Suboxone?", "acceptedAnswer": "@type": "Answer", "text": "It depends on the tapering schedule followed. Always check with your healthcare prescriber before changing your current medication schedule, but as a rough example, tapering off a 16mg/day dose would take over 45 days. According to information from the University of Nevada, Reno School of Medicine, it will take 2 to 3 days to clear buprenorphine (Suboxone) after the last dose." , "@type": "Question", "name": "Is 4 mg of Suboxone a lot?", "acceptedAnswer": "@type": "Answer", "text": "According to the prescribing information, the dosage strengths for a sublingual film of buprenorphine (Suboxone) is: buprenorphine 2 mg/ naloxone 0.5 mg, buprenorphine 4 mg/ naloxone 1 mg, buprenorphine 8 mg/ naloxone 2 mg, and buprenorphine 12 mg/ naloxone 3 mg. Thus, 4mg of buprenorphine (Suboxone) would be about an average dosage strength." , "@type": "Question", "name": "What happens if you run out of Suboxone?", "acceptedAnswer": "@type": "Answer", "text": "If you are running out of buprenorphine (Suboxone), it is best to consult with your healthcare provider to develop an appropriate action plan until your next refill. Your healthcare provider may suggest cutting films if you have a few remaining doses of buprenorphine (Suboxone) left. Your healthcare provider may also suggest scheduling an appointment to discuss this issue further as they may be able to adjust your next prescription dosage to better meet your needs and to avoid running out of medication in the future." , "@type": "Question", "name": "Can you take half a Suboxone?", "acceptedAnswer": "@type": "Answer", "text": "It is best to follow the buprenorphine (Suboxone) prescription given by your healthcare provider. If you are following a tapering schedule that you developed with your healthcare provider, the recommendation may be to take half of a buprenorphine (Suboxone) strip." , "@type": "Question", "name": "What happens if I miss a day of Suboxone?", "acceptedAnswer": "@type": "Answer", "text": "According to the National Alliance on Mental Illness (NAMI), if a person misses a dose of oral buprenorphine (Suboxone), they should take it as soon as they remember unless it is closer in time to when the next dose is usually taken. NAMI recommends that people not double their next dose of buprenorphine (Suboxone) or take more than what is prescribed." ]
I have been on suboxone for 7 years, and i can tell you for sure tapering slowly is the only way to do it. You should do a tapper 6 months per every year you gave been on it . If your on it two years you should do a 1 year tapper.using the film.i was on methadone for 20 years and took 2 years to come off, but this suboxone for me was harder. Once i got to two milligrams i went to a 1/8 cut instead of a 1/4. But do it slow and you will still be able to work. Exercise is important to , its hard but it helps. Plus other things lime clonidine to help you sleep once you get down to 1mg.
Suboxone films are U.S. Food and Drug Administration approved to treat opioid dependence. While the package insert states that films should not be cut, physicians often prescribe film fractions for treatment and tapering. There is no data to support this practice, and this study was initiated to evaluate cutting methods, content uniformity, and stability of split films. Suboxone 8-mg buprenorphine/2-mg naloxone films were split using four methods: 1) ruler/razor cut, 2) scissor cut, 3) fold/rip, and 4) fold/scissor cut. United States Pharmacopeia Chapter was used to evaluate the weight variation and content uniformity of split films. The stability of split films stored in polybags was evaluated over 7 days. A stability-indicating high-performance liquid chromatography method was used for content uniformity and stability evaluation. The weight variation results were acceptable for the half films from all four cutting methods, but this was not true for the quarter films. The method of ruler/razor cut was determined most favorable and used for the content uniformity test. Based on the high-performance liquid chromatography results, the half films from the ruler/razor cut method met the passing criteria of United States Pharmacopeia Chapter with acceptance values of 9.8 to 10.4 for buprenorphine and 8.4 to 11.5 for naloxone (=15 is considered passing). The stability results indicated that both actives retained >97.7% of initial strength. Four cutting methods were found to be acceptable for splitting Suboxone films into half but not quarter fractions. The half films from the ruler/razor cut method also passed United States Pharmacopeia Chapter content uniformity test. Both actives remained stable for 7 days when the half films were stored in polybags at room temperature.
Abstract:Buprenorphine is a partial opioid agonist that is Food and Drug Administration (FDA) approved to treat chronic pain and opioid use disorder (OUD). The national prescribing guidelines in the United States (US) recommend that patients transitioning from full opioid agonists to buprenorphine first undergo 12 or more hours of active opioid withdrawal, in order to avoid buprenorphine-precipitated opioid withdrawal. This opioid-free period imposes a significant barrier for many patients. Evidence is accumulating that using microdoses of buprenorphine to cross taper from full-agonist opioids to buprenorphine is a safe and effective way to avoid opioid withdrawal and uncontrolled pain. This microdose cross-tapering strategy is already being used across the US. The US prescribing guidelines and buprenorphine training would benefit from acknowledging this new approach. Additionally, to facilitate this strategy, the FDA should approve transdermal buprenorphine formulations for OUD and manufacturers could produce lower dose formulations of sublingual buprenorphine. The time has come for us to embrace buprenorphine microdosing cross tapers as a new standard of care.Keywords: chronic pain; cross taper; microdose; microinduction; buprenorphine; induction; opioid use disorder; addiction; overdose; opioid
The injectable, long-acting bupe shots, such as Sublocade and Brixadi, may provide a very gradual tapering, without the patient having to worry about focusing on cutting their medication over time. The idea of using a single buprenorphine shot as the final drop-off dose is intriguing and should be studied further.
Following a Suboxone film cutting guide online, working with a razor and metric ruler, can be difficult. Tapering by cutting Suboxone films can lead to uneven dosing and inadequate treatment during the tapering process.
In fact, patients sometimes present to their doctor to get a Suboxone prescription with a secret plan of using the medication to follow a one-week Suboxone taper or a two-week taper that they found on some website. Of course, I do not recommend taking medical advice from websites.
Opioids can cause sleep-related breathing disorders including central sleep apnea (CSA) and sleep-related hypoxemia. Opioid use increases the risk of CSA in a dose-dependent fashion. In patients who present with CSA, consider decreasing the opioid dosage using best practices for opioid taper [see DOSAGE AND ADMINISTRATION].
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