I have many patients who have been stable on Suboxone for a long time, sometimes for years, who come to me and ask to taper off their dose in the hope that they can get off the medication altogether. I have used blood pressured medication and insulin as examples to explain why Suboxone is a maintenance medication that needs to be taken continuously, but these patients never seem convinced. They feel that they are not ‘succeeding’ or are not ‘sober’ while they are taking the medication, even if they are living full, healthy, happy lives. I’ve talked a lot on this blog about why I believe people come to feel this way, and why I disagree with their reasoning. I haven’t spent as much time talking about the reason why I try to dissuade my patients from trying to taper off. The reason is very simple: it doesn’t work.
With some medicines, tapering off is a valid strategy. Antibiotics work like catapults or bombs; they are a way to kill a large number of invading enemy organisms very quickly. Once most of the invaders are dead, the problem is over, and more antibiotics won’t do any good. There’s no point in firing weapons at an empty field with no enemy soldiers on it. After following the prescribed course, the patient can stop taking the antibiotics and return to their normal lives, feeling perfectly healthy. Other medicines, like non-narcotic painkillers, are given only for a short time because the human body can heal itself without their help. Something you would need to take painkillers for — say, a cut from a surgical procedure, or a broken bone — will repair itself whether or not you take medication; the painkillers are only to help you feel more comfortable along the way. Once the body’s healing process is finished, there’s no need for you to feel more comfortable, so the painkillers can (and should) be stopped with no ill effects.
Buprenorphine works very differently from either of these examples. Addiction isn’t caused by any invading organism, so taking one massive dose and then stopping the medication won’t do any good. Many people seem to think that buprenorphine will work like other painkillers, and that the brain will repair itself while they take it, but for the vast majority of people this simply isn’t the case. The damage caused by addiction affects a very delicate part of the brain, which won’t heal on its own the way a broken bone will. Our current understanding of the disease of addiction is that the damage caused by addiction is permanent, so the symptoms will also be permanent, unless they are treated by a maintenance medication like buprenorphine. 12-step and counseling programs sometimes tell their clients that the brain can repair itself after a certain amount of time and counseling, but there is absolutely no solid science to back up such a claim. As soon as a patient stops taking buprenorphine, the underlying damage asserts itself again and the symptoms return, which very often leads to relapse.
A good way to think about this is to imagine the damage caused by addiction as a leaking crack in a dam, and imagine that the dam is holding back a reservoir from flooding the town where you live. It’s fairly easy, and VERY important, to put a patch over the crack to keep it closed; if you don’t, then the water pressure will make it wider, and it will be harder and more difficult to seal up later. As long as the patch holds, life can go on as normal in the town, but the patch isn’t fixing the underlying crack or causing it to “heal” itself magically. All the patch is doing is keeping the damage from getting worse, and keeping the people in the town from suffering the consequences of a break. If the patch is ever removed, the water will immediately start leaking through again, pushing the crack wider and causing a flood.
Using this image, we can think of buprenorphine as a patch over the damaged parts of the brain, holding back the flood of symptoms, cravings, and damaging behaviors that addiction will cause if left untreated. It doesn’t fix any of the underlying damage. It only keeps it from getting worse and keeps it from negatively affecting a patient’s life. In my experience, patients who taper off their medicine because they feel that they aren’t fully ‘clean’ will suffer a relapse in almost all cases.
Providing patients with the complete truth is very important when they have questions or concerns. I always tell my patients that while it is possible for a very few people to taper off Suboxone successfully, for most people it is harmful and counter-productive, and I rarely recommend it. Understanding how buprenorphine works and what it does and does not do is essential to a comprehensive and effective treatment, and I would hope that all prescribers of buprenorphine take the education of their patients and their loved ones very seriously.