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Knowing If & When To Taper

Richard Ries, MD
Professor of Psychiatry, University of Washington Medical School
Director, Chemical Dependency Project, Harborview Medical Center
Seattle, WA

A 19-year-old woman with OUD (IV heroin), a history of depression and self-harm presented to Harborview Medical Center’s Addiction Services in Seattle, Washington. She was on an SSRI and lamotrigine, and was homeless after recently arriving from across the country. She was quite ill when she presented herself for help with all of the above.

Seeing that she was in withdrawal, I took a very brief history then prescribed 8 mg of Suboxone, maintained her other medications, and enrolled her in our clinic’s buprenorphine addiction treatment program, which she attended two times a week. She also began seeing a counselor. She stabilized, but had continued issues of housing, relationships, and her Borderline personality. Both her counselor and I utilized 12-step facilitation, even though she was originally quite resistant.

Two years later she was in college, with a stable mood and relationship, regularly attending Narcotics Anonymous (NA), and wanted off buprenorphine. Because she had made so much progress and had lab tested and reported sobriety of almost 2 years, I supported her request. The tapering process was gradual over four months, and following the completion of the taper, she appeared to be stable. By this time she was only seeing me monthly, was done with her agency groups, but was still attending NA.

About two months later, she came to the clinic and said, “Dr Ries, I died last night. The ambulance guys said I was dead for almost a minute. I relapsed to heroin for two days and I took too much. I think I better go back on Suboxone.” I immediately re-prescribed 8 mg of buprenorphine, relinked her with our group, made sure she was still active in NA.

That was all four years ago. I just saw this patient this week, and she brought her healthy smiling two-year-old girl to session, as she always does now. The patient and her husband are both on buprenorphine at stable 8 mg doses, and there has been no drug or alcohol use in either for four years now. Both have also stopped smoking. She continues with episodic NA and stays in touch with her sponsor. My patient finished college with a 3.9 grade point in mathematics, and works regularly in child care for underprivileged kids, while her husband is a professional house painter.

What I have learned from this and some other stories like this is: opioid addiction is tenacious, and even though a patient is doing everything right, and stabilized in most or all sectors of their life, opioid addiction can come back out of seemingly nowhere – and come back in a lethal manner. These days I have become much more reticent to taper patients off buprenorphine, and my usual answer to taper requests is: “Let’s not taper things until you have been stable at least as long as you were mired in your addiction, stabilized in most or all areas of your life. And if and when you stop, take naltrexone injections for at least 3 months.” A naloxone rescue kit is supplied too.

While we don’t yet have data from studies to support all of my recommendations, this has been my clinical experience, and I have learned to be very careful when it comes to patients’ or others’ requests for stopping their buprenorphine.

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