The Cold Hard Truth About Tapering Off Methadone
As a medical director of a methadone treatment program, more and more individuals come to me to taper off methadone after achieving stability in treatment. I want my patients to succeed and I never want to discourage them. However, I need to be truthful with them. The research reveals most tapering attempts fail, but every patient proceed ahead thinking they will be the ones who succeed. Before considering tapering, patients should understand the immense difficulty involved and how to give themselves the greatest odds of success.
The Difficult Methadone Detox
Recent scientific investigations shine light on the long odds patients face when attempting to taper off methadone. One study reviewed patients’ ability to completely taper off methadone over a multi-year period within a treatment program generally intended for indefinite maintenance. Zero participants successfully finished tapering off methadone. Only 13% were able to transfer to buprenorphine first before stopping that medication as well.
Another analysis examined relapse rates after patients reduced their methadone dosage. Within just 12 months after beginning to taper, 31% had returned to illicit opioid use. In all, these findings indicate accomplishing a successful taper remains astonishingly rare even under favorable circumstances.
Yet, some patients want to taper off opioid agonist therapy due to life goals, desire to eliminate long-term medication use, and to eliminate required clinic visits. Therefore, when appropriate, I strive to support patient autonomy and choice through a collaborative tapering process. However, given the long odds, taper attempts require extraordinary patient motivation and consistent professional guidance to have any chance of success without relapse.
Essential Elements of a Gradual Methadone Taper
Research clearly demonstrates far higher rates of relapse if dosage decreases fast versus extremely slow. Therefore, experts emphasize establishing an initial taper rate of less than 5mg per week when attempting to taper off methadone. Patients tapering any faster showed markedly worse outcomes. While this is what the research shows, I encourage an even slower pace at 1mg every other week.
Additionally, the tapering rate should be individualized based on the patient’s history and risk factors. According to the research articles, patients with lower relapse risk before tapering will do best initially reducing their dose at less than 2.5mg per week.
Adding in flexibility is vital as well. When necessary, pause the tapering to stabilize and eliminate any methadone withdrawal symptoms. Temporary small dose increases can alleviate any cravings. Monitoring withdrawal symptoms, continuing psychotherapy, and emotional support serve as the backbone of the tapering process. Without intensive bio-psycho-social treatment assistance, the chances of failing increases.
Key Predictors of Tapering Success
Analyses of the data reveal several key factors associated with higher chances of successfully tapering off methadone:
Duration of Prior Methadone Treatment – Multiple studies link longer continuous addiction treatment of over one year before tapering attempts to significantly improve outcomes. This likely reflects the cumulative benefits of counseling, psychological well-being, and overall improved personal stability. All of which can occur with extended participation in the treatment program
High Attendance Rates – Similarly, sticking closely to the treatment regimen before and during dose decreases lowers relapse risk after tapering ends.
Commitment to Tapering Off Medication – Like all difficult personal goals, a strong level of motivation and follow-through is critical to succeed with tapering.
Psychiatric Stability – Preexisting psychiatric instability – especially depression and anxiety – will derail tapering attempts. Proactively treating any psychiatric illnesses is important to succeed with tapering.
Avoiding Substance Use Temptations – Unsurprisingly, avoid triggers. Don't hang out with other substance abusers..
Do These Things Before You Taper Methadone
Before you consider tapering off methadone, it's crucial to know that while some patients do it successfully, most fail. Understanding this helps set realistic expectations and plans. Here’s how to prepare:
Personal Stability – Make sure your life is stable. This includes relationships, housing, job, and health. You need to be in a good place because tapering methadone can be physically and emotionally tough.
Treatment Stability – Have a solid sobriety record for several years before you think about tapering methadone. Work with your doctor to create a slow and steady plan for tapering.
Social Support – It’s important to have people around who support you positively. They can give you encouragement, help you stay accountable, and be there for you when things get stressful. Trying to do this alone is risky.
Coping Strategies – Know what triggers you, the warning signs, and situations that are risky for you. Plan ahead on how to deal with these using strategies that align with your personal values.
Slow Down – Make a very slow tapering plan. But don't push yourself if. It is ok to slow things down especially when the studies show that speed = failure.
Progress Monitoring – Keep an eye on any changes in your emotions, how you function, or your behavior with your treatment team. If you notice anything concerning, get help right away.
Don't Forget Nutrition - Make sure you are pursuing tapering with adequate nutrition. This is an area that is often overlooked. During tapering, your brain has to recover from neurotransmitter imbalances. Micronutrient deficiencies may make this process longer and harder to accomplish.
Remember, tapering off methadone requires a stable life, a well-thought-out plan, lots of self-care, strong social support, careful clinical supervision, and the ability to adapt. Without these, the chance of problems increases significantly.
The Cold, Hard Truth
In the end, science, patients and doctors agree that stopping methadone is extremely hard and often doesn't work out. Success depends a lot on your own determination, having support from others, and getting your treatment tailored to you. Even with all of these, chances are high you might face difficulties, fall back into opioid misuse, or need to continue medication for opioid addiction for a long time.
But what's more important than the end result is the lesson you learn: being functional and law abiding is the real measure of success, not just reaching a goal of being off of methadone. Every small step forward is a chance to grow. The journey of tapering off methadone, like overcoming addiction itself, needs a lot of perseverance, honesty with yourself, and the support of people who care about you. No matter where the journey of tapering takes you, commit to your best health and being your best self every day. That's where you'll find true freedom.
Calsyn, D.A., Malcy, J.A, & Saxon, A.J. (2006). Slow tapering from methadone maintenance in a program encouraging indefinite maintenance. Journal of Substance Abuse Treatment, 30(2), 159-163. https://doi.org/10.1016/j.jsat.2005.11.007
Wang, C., Fan, C., Lu, Q., Chen, W., Liu, Y., Xu, C., Tang, X., Zhou, W., & Ling, L. (2022). Exploration of dose tapering strategies for methadone maintenance treatment based on relapse risks: A subpopulation treatment effect pattern plot (STEPP) analysis. Drug and Alcohol Dependence, 238, 109581. https://doi.org/10.1016/j.drugalcdep.2022.109581
About the author:
Dr. Harold Pierre is a board-certified anesthesiologist and addiction medicine specialist with over 20 years of experience. He is certified by the American Board of Anesthesiology and the American Board of Preventive Medicine.
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