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Discontinuation of Buprenorphine for Opioid Use Disorder: Methods and Risks

Maria Gabriela Castro, MD
H. Claire West, MD
E. Blake Fagan, MD

American Family Physician. 2026;114(2):158-163.

Author Disclosure: No relevant financial relationships.

This clinical content conforms to AAFP criteria for CME.

In the United States, opioid use disorder affects approximately 9.5 million people and has contributed to more than 50,000 opioid-related overdose deaths in 2024. Buprenorphine treats opioid cravings, alleviates withdrawal symptoms, and reduces opioid overdose risk and all-cause mortality by more than 50% each. However, discontinuation is common and often patient-driven. Longer periods of maintenance therapy (longer than 12 months) and slow, individualized taper rates (decreasing by 2 mg/month or less) are associated with lower overdose risk, lower rates of opioid use, and higher rates of taper completion. Evidence also supports use of adjunctive medications to treat withdrawal symptoms and harm reduction strategies such as naloxone provision and ongoing follow-up. Because the optimal duration of buprenorphine maintenance therapy is not known, the decision to discontinue should be clinically supported, patient-centered, and voluntary. Clinicians should prioritize shared decision-making, flexible tapering plans, and overdose prevention to mitigate risks. For some patients, sustained dose reduction may be a more feasible end point than complete cessation.

Opioid use disorder is a chronic and relapsing condition affecting approximately 9.5 million people in the United States.1–3 In 2024 in the United States, opioid-related overdoses contributed to more than 50,000 deaths.2 These overdoses were primarily associated with illicitly manufactured fentanyl, whereas previous overdose trends were driven by heroin and prescription opioids.1,2 Buprenorphine is an evidence-based, first-line medication that treats withdrawal symptoms and provides long-term relief from opioid cravings.4–6 It acts as a partial agonist at the mu-opioid receptor and exhibits a ceiling effect for euphoria and respiratory depression but not analgesia.4–6 Any clinician with Schedule III authority can prescribe buprenorphine in any setting, including primary care, and it can be dispensed for take-home dosing from any commercial pharmacy. A previous American Family Physician article reviewed common questions regarding buprenorphine treatment for opioid use disorder.7 Although other medications can treat opioid use disorder (eg, methadone, naltrexone, long-acting morphine), this review focuses on discontinuation of buprenorphine.

SORT: KEY RECOMMENDATIONS FOR PRACTICE

Clinical recommendations Evidence rating Comments
Buprenorphine maintenance therapy should be continued as long as it benefits the patient to support long-term remission and reduce the risk of overdose.4–6,8–12 A Systematic reviews, meta-analyses, national practice guidelines from ASAM, clinical guidelines from CRISM, and PEER opioid use disorder guideline
To decrease the risk of overdose, patients should complete at least 12 months of buprenorphine maintenance therapy before starting a taper.4,12,24,25,31 B Cohort studies, national practice guidelines from ASAM, and clinical guidelines from CRISM
To decrease the risk of overdose, buprenorphine tapers should be slow and individualized. Dose reductions of no more than 2 mg/month should be considered, and adjustments should be made no more than every 1–2 months.4,5,12,11,31 B Cohort study, national practice guidelines from ASAM, clinical guidelines from CRISM, and PEER opioid use disorder guideline
Physicians should provide close follow-up for patients who discontinue buprenorphine after taper completion to support recovery and assess the need to restart treatment.4,8–10 C National practice guidelines from ASAM, clinical guidelines from CRISM, and PEER opioid use disorder guideline

ASAM = American Society of Addiction Medicine; CRISM = Canadian Research Initiative in Substance Matters; PEER = Patients Experience Evidence Research.

A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited-quality patient-oriented evidence; C = consensus, disease-oriented evidence, usual practice, expert opinion, or case series. For information about the SORT evidence rating system, go to https://www.aafp.org/afpsort.

MARIA GABRIELA CASTRO, MD, is an associate professor in the Department of Family Medicine at the University of North Carolina at Chapel Hill School of Medicine, Chapel Hill, and the data team lead at the North Carolina Substance Use Treatment and Recovery Network, Chapel Hill.

H. CLAIRE WEST, MD, is an associate professor in the Department of Medicine Division of General Medicine and Clinical Epidemiology at the University of North Carolina at Chapel Hill School of Medicine, Chapel Hill, and the program director at the North Carolina Substance Use Treatment and Recovery Network, Chapel Hill.

E. BLAKE FAGAN, MD, ABPM-ADM, is a professor in the Department of Family Medicine at the University of North Carolina at Chapel Hill School of Medicine, Chapel Hill, and the clinical director of substance use disorders at the Mountain Area Health Education Center, Asheville, North Carolina.

Address correspondence to Maria Gabriela Castro, MD, at gabriela_castro@med.unc.edu.

Author Disclosure: No relevant financial relationships.

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