Discontinuing Methadone and Buprenorphine: A Review and Clinical Challenges

Abstract

This paper offers a review and recommendations for clinicians working with patients interested in discontinuing opioid agonist treatment. As buprenorphine/naloxone has gained widespread acceptance for opioid addiction, many treatment providers and patients have a range of hopes and expectations about its optimal use. A surprising number assume buprenorphine/naloxone is primarily useful as a medication to transition off illicit opioid use, and success is partially defined by discontinuing the medication. Despite accumulating evidence that a majority of patients will need to remain on medication to preserve their gains, clinicians often have to address a patient's fervent desire to taper. Using the concept of “recovery capital,” our review addresses (1) the appropriate duration of opioid agonist treatment, (2) risks associated with discontinuing, (3) a checklist that guides the patient through self-assessment of the wisdom of discontinuing opioid agonist treatment, and (4) shared decision making about how to proceed.

Duration of use and outcomes among people with opioid use disorder initiating methadone and buprenorphine in Ontario: a population‐based propensity‐score matched cohort study

“…These changes provide an opportunity to expand access to methadone, for example, through primary care and emergency department settings. The differential risks of overdose, treatment retention and frequency of engagement with health-care providers that are observed between methadone and buprenorphine reinforce the importance of shared decision-making between clinicians and their clients [37,38] to personalize OAT selection and identify opportunities to optimize treatment retention.…”

Patients’ Perspectives on Coming Off Opioid Agonist Treatment: A Qualitative Study

“…Over the 60 years since the introduction of OAT, different standpoints have developed over the issue of treatment length. 17 Some argue that patients with OUD—like patients with diabetes or other comparable conditions—should maintain lifelong treatment. 17 For others, the ultimate goal is to assist the patient to withdraw from OAT and lead a drug-free life.…”

“… 17 Some argue that patients with OUD—like patients with diabetes or other comparable conditions—should maintain lifelong treatment. 17 For others, the ultimate goal is to assist the patient to withdraw from OAT and lead a drug-free life. 17 , 18 Countries differ in their treatment policy concerning the purpose and length of OAT.…”

“… 17 For others, the ultimate goal is to assist the patient to withdraw from OAT and lead a drug-free life. 17 , 18 Countries differ in their treatment policy concerning the purpose and length of OAT. In the United States, national authorities advocate for abstinence as a goal for OAT.…”

Addiction Treatment Networks Cannot Withstand Acute Crises: Lessons from 2021 Winter Storm Uri in Texas

“…Some patients were able to arrange "guest dosing" from other nearby OTP clinics during limited hours or were able to obtain early "take-home" doses arranged prior to the storm. Others, however, were unable to obtain methadone and began to experience withdrawal, which profoundly increases the risk for recurrence and overdose [1].…”