The Sliver Plan: a Suboxone Taper

By Laura C. Meyer 08/16/17

The mind and body can attach to Suboxone like it's a security blanket; so we minimize fear of withdrawal by slivering off such a small amount that it's not even noticeable.

Woman putting pills into daily pill organizer

I've heard it all. Okay, maybe not all, but most of it. When I open conversation about a Suboxone taper, it inevitably leads to fear.

Suboxone clients are referred to my office from the prescribing doctor for a few different reasons. Most clients on Suboxone are not required to do any counseling, nor do we provide counseling. We have referred clients to therapy when needed, but my role with them is not to provide therapy. In ten years of working in the field of addiction -- eight specific to opioid addiction -- I have found that stress management and mindful awareness skills move clients quickly toward lifestyle changes.

Clients enter my office to learn how to tolerate any stress of recovery; to increase awareness of themselves; and/or to get support for a successful opioid taper. Clients spend their time and money in our office, and we want to offer all we can to ensure success.

Whether just starting Suboxone or not, within the first few months I ask about a future taper. Most our clients plan to taper at some point, so it's worth having the conversation.

I tell them the reason I like to know is that a taper doesn't start when they decrease the medication. Our taper plan (The Sliver Plan) can start a year or two before any medication changes, and if they want to taper in the future, we might as well get started.

In eight years of helping clients taper from Methadone, Suboxone, and newer Buprenorphine/Naloxone medications, here are the methods that have given clients the best results:

First, The Sliver Plan includes the client, the doctor, and me. This is not a perfect plan, but it does represent the general flow of most clients.

The Pre-Readiness Stage -- before we make any medication changes -- can take months and is more about inquiry and exploration. We start exploring the idea of a taper. We inquire into any fears, concerns, and any horror stories they've either read on the internet or heard from friends.

Most clients hold onto fearful memories from past withdrawal experiences. I inform them that The Sliver Plan will not be reminiscent of past withdrawals. This plan is designed to actually not have the clients feel any discomfort in the first few months, and maybe mild discomfort after that--but we try to minimize or eliminate withdrawal symptoms altogether.

No pain from withdrawal is key. Life can present our clients with enough discomfort while they are in recovery, so we try to avoid any added stress or pain.

When we do start decreasing medication, the plan is to sliver off a piece small enough that it's not noticeable. In the first few months of decrease, it's important to give the mind and body a chance to trust the new changes by not initiating any discomfort.

The mind and body can form an attachment to the medication like it's a security blanket, and we treat the medication as if it were a literal security blanket: although the goal may be to leave it behind, we know that separating too quickly can cause trauma and relapse. The goal at this stage is to start noticing an inner sense of hopefulness and motivation; not pain.

I sometimes use the example of a 12 oz. cup of coffee (let's say in comparison to 12 mg of medication). If I decrease from 12 oz. to 11.75oz., chances are I won't even notice. Then we stay there until 11.75oz. is our new normal. Then we can decrease to 11.5 oz. Each time I reduce by a measurement that I won’t notice, and I stay there until I feel safe and at ease with the new amount.

This is where clients can start to let go of any horror stories, past fears of pain, and learn to rely on their own inner knowing; because there is no set timing, amount, or correct way. The taper process is as individual as one's fingerprint.

Teaching clients to be in (and with) their own process, they begin to feel their own body, to observe their own mind, and begin making decisions based on their individual experience. They are making choices founded on their own observations, individual needs, and motivations. This process becomes a microcosm in learning to navigate themselves in daily life.

At this time we look closer at the following:

Are they motivated by time, such as every two weeks, or once a month?

Are they motivated by a number such as .5mg?

Some clients are visual and motivated by charts.

Some clients are motivated by inner progress. Simply knowing they are tapering is enough, and they may go slower than other clients.

Some clients are okay with tapering a bit more and want to learn to work with some physical discomfort. Learning when to push through and when to rest becomes important here.

What do they want to do when life gets stressful? Do they keep going or pause the taper?

What time of day, and which dose (for those who split dose) will be easiest to let go?

Do we need to shift medication to morning or evening?

Timing of holidays, work, and school schedules. One client wanted to take his last dose over spring break, so we timed it accordingly. I've had clients save vacation days for the final days.

Aftercare, such as future surgeries that may require pain medication.

During the medication taper, we look at anything that comes up physically and mentally, and treat each symptom as it arises. Clients learn to access any valid withdrawal, compared to any lifestyle changes that may be needed.

Decrease in sleep or energy? We allow the body time to adjust (reset) while simultaneously looking at current sleep routines, any energy drains, and ways to increase energy. Feeling uncomfortable emotions? We learn to be with them differently.

We also look at any mental manipulations, such as hoarding the slivers, and/or becoming overly obsessive anywhere in the process.

Some last-minute tips: Stress is fuel to the fire of addiction, and learning to manage stress becomes vital to a taper. We spend more time with our clients on creating goals and a new vision, and less time circling in their past. With medications in pill form, a pill cutter is helpful. We do allow clients to save a few slivers for support, and for those who can get overly motivated and take off too much. The Sliver Plan starts before any medication changes, and does not end the day of the last dose. We keep the doors and phone lines open to our clients.

Lastly, I want to mention the importance of time. We guide our clients through The Sliver Plan to the very end, as little of a sliver as we can get. Our clients gain most success from going slowly, and we encourage it. There is no set time, order, or plan: it's as unique as a fingerprint, and helping clients discover their own uniqueness is part of our process.

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