I recently had a chance to sit down with Dr. Benjamin Schwartz and talk with him about the tapering process. Tapering completely off of Suboxone, Subutex, or one of the alternative medications is a goal of a lot of our patients who don’t have a medical reason, such as chronic pain, to continue on the medication long term have. However, sometimes determination alone isn’t enough and people need to have a good plan to follow when looking at starting and finishing a taper
Me: What’s some important things to keep in mind when a person wants to taper off Suboxone or one of the alternatives.
Dr Schwartz: People really need to remember it’s all about percentages and not milligrams. How much you are taking isn’t as relevant as how much of a percentage reduction you are doing. Going from 20mg to 16mg is about a 20% reduction. That’s what we want to aim for 10-20%. That’s why as patients get lower we slow the taper down or it seems to take longer, we are still trying to stay in that 10-20%.
Me: So what does a basic taper look like starting out.
Dr Schwartz: The nice thing with the 12, 8 and even 2 mg doses is that it’s a fairly simple process to gauge how much will be half, a quarter, or so on and you can cut the medication up while tapering. A person can separate ¼ of an 8 mg strip in order to take 6 mg. We generally start with a goal in mind for the patient during their initial or ongoing taper. Say you are at 8mg and want to go to 6mg. We will suggest alternating days between 8mg and 6mg and as people get to where they tolerate that well we can go to 6mg daily.
Me: I know in my own experience in medication assisted treatment that dropping off completely at 2 mg can be difficult for people. What do you do about people who aren’t ready or have tried before to stop at 2mg and weren’t successful, but still want to be off the medication.
Dr Schwartz: Good question. We have a couple solutions for that. The first is the Butrans patch which is a time release patch that delivers the same medication, only in micrograms as opposed to milligrams. Unfortunately the patch is only FDA approved for pain so we often run into issues with their insurance covering it. We can also work with a compound pharmacy to make specific dose levels of the medication so the patient can split the doses in smaller units and take it more frequently through out the day. If neither of these can be done b/c of cost or for whatever reason, we have developed calenders with specific doses to comfortably taper off suboxone completely in 2-3 months.
Me: I know a lot of patients worry about withdrawal, and certainly many people have returned to using to combat withdrawal. What can you do to help or alleviate their fears.
Dr Schwartz: Tapering off any medication on which someone is physically dependent is never, or rarely, going to be a pain free process. The pain here though is more discomfort then actual pain. My personal experience tells me that people who are active in their lives with work, family, activities they enjoy, etc… report much less withdrawal symptoms compared to people who do nothing but sit around thinking about how they don’t feel well. That being said there are also short term, non narcotic medical interventions and medications we can use to help people “over the hump,” if they need it. Talk to one of the medical staff at your next visit if you have concerns.
Me: What’s the biggest barrier you see people having in tapering.
Dr Schwartz: Fear. Really that’s it. If you do it correctly, and follow a protocol, the symptoms if present, are manageable. People convince themselves it will be worse then it is. One of the counselors here talks about it in New Patient Orientation as a “Self Fulfilling Prophecy.” You convince yourself it’s not doable and before you know it you have talked yourself into worse symptoms then you actually have. Part of that is people hearing from a friend or reading on the internet somewhere that getting of Suboxone is worse then Heroin, which is categorically untrue. They have done studies side by side of people coming off both and the people on Suboxone reported far less severe symptoms.
Me: What about people with ongoing chronic pain issues. People who crossed over into addiction as a direct result of abuse of the pain meds they were prescribed. Are they going to need to be in treatment for life?
Dr Schwartz: That’s a two part answer. If a person comes to us with chronic pain issues as well as addiction issues, we need to address both of those. Pain doesn’t motivate people into treatment. In fact more often then not it gets them to continue in or return to active use and abuse of opiates. Our question for anyone with chronic pain is “What are you going to do to manage your pain if you completely taper of Suboxone (or another alternate medication)?” If the answer is to go back, or believe you can go back to using short acting pain meds like Oxycodone to deal with the pain, then you are going to be back here needing help again in a few months. We work with our patients by making referrals when needed to specialist. Sometimes though people need the pain management portion of Suboxone long term and that’s fine. And no you won’t be in treatment for life. We also have a pain management program and have several patients who are using Suboxone as their primary pain management. You will need to spend at least a year on the therapy side while the issues surrounding your addiction are addressed and dealt with, but after some time we can, with the proper documentation, move people over to a purely pain management program. But again, that’s after they have proven to be successful in the addiction treatment piece. We don’t move people just because it’d be more convenient if you just didn’t have to go to group therapy or counseling.
Me: Any last piece of advice?
Dr Schwartz: Don’t rush it. That’s the one thing I see cause people more problems then any other. They are getting near the end and just want to be done, so they stop or go down too quickly, then we are getting a call from them in a few months needing help again, and then the process starts all over again. Also work with your counselor to develop an aftercare plan. You didn’t get here overnight and just because you aren’t on the medication any more doesn’t mean you don’t have addiction issues. Addiction can be put in remission, but it can’t be cured. Having support as you continue to move forward in life and recovery is vital to success. The counseling staff is always pointing out all of these paradoxes in recovery. “Surrender to win,” and that sort of thing. One of them is “After a while it stops being about the drugs, alcohol, gambling, etc…and is about living life on lifes terms. However, it’s always about the drugs, alcohol, gambling etc…” I think what that’s saying is that people are always going to have this disease. Just because you successfully completed treatment and are done with medication doesn’t mean your brain has somehow miraculously reset itself and you can pick up and use responsibly. The people who succeed are those take the tools they learned in recovery and use them as they move forward.
Here at Recovery Works NW we have decades of combined experience in treating and dealing with addiction issues whether they be opiates or another substance. If you or a loved on is struggling with Opiate Dependence or another similar issue, please give us a call. We have the team in place to help you get back on your feet and back to what’s important. You.
Dr Schwartz or one of the other doctors speak at the New Patient Orientation group on the 3rd Saturday of every month. If you or your family, support, etc.. have questions, that’s a great place to have questions about the medication and the program addressed.