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How long will I be on opioid agonist therapy?

This is one of the most frequently asked questions, and one of the most difficult questions to answer.

There are two different schools of thought concerning length of treatment. One approach looks at agonist therapy as long term, and possibly indefinite—like insulin treatment for the person with diabetes. Opioid addiction is explained as a biological disorder, and opioid agonist therapy (OAT) is the medicine used to treat the condition.

The other approach looks at maintenance as a shorter-term treatment. This approach sees opioid addiction as the result of the person’s attempts to solve emotional problems with drugs. When the person who uses opioids learns to deal with problems in other ways, and their life becomes stable and happier, there is less reason to look to drugs for help.

OAT is seen as allowing the person the chance to get well and get their life in order. Once this is accomplished, the person can then taper off methadone or buprenorphine. Short-term agonist therapy is usually one to two years.

There is truth in the ideas underlying both long- and short-term treatment approaches. Opioid addiction does change the way the brain works in that it suppresses the brain’s ability to produce the body’s natural opioids, endorphins. People who withdraw from opioids, including methadone or buprenorphine, may feel emotionally low and have trouble sleeping long after withdrawal. It’s also true that having a supportive home life, a good counsellor, meaningful employment or other activities, and a strong desire to be drug free can help make the period after withdrawal easier to get through, and less likely to result in a return to opioid use.

You should know that those who withdraw from OAT after short-term treatment are more likely to return to opioid use than those who stay in treatment. This is why many doctors and counsellors encourage clients to stay in treatment for at least 12 months, and possibly long-term.

Keep in mind that the consequences of long-term agonist therapy are minimal compared to the dangers of using street opioids. Long-term use of methadone or buprenorphine has no effect on the internal organs, or on thinking. If it helps you to lead an active and happy life, then it is well worth the inconvenience, the side-effects, and any possible stigma you may encounter from people who do not understand the nature of your treatment.

I thought maybe two, three years. It’s restrictive, it’s a time commitment. Travel is hard. I’m tied to it.

Ruth, 64 | Methadone, 22 years

I remember saying to a friend, I will probably be on methadone for the rest of my life. It’s not an issue. You drink your juice every day. However, you do get married to the doctors, the clinics, the drugstore—it is a downside, but it’s a small downside compared to my previous existence.

Glen, 59 | Methadone, 15 years

OAT is not a cure. After you are off it, you have to figure out the root cause of your addiction or there is a good chance you will be back on it, or develop another addiction. You need counselling or support groups to make it. It gets rid of the physical sickness, but not the disease.

Jon, 41 | Methadone, 5 years and

buprenorphine, 1.5 years

I have thought about tapering off, but I know that it improves my mood (more than any antidepressant I have ever taken) so for right now I am content to use it.

Jessica, 36 | Methadone and

buprenorphine, 3 years

I think it is going to be life-long. With my Crohn’s disease, I’m going to require some kind of maintenance. It’s either methadone or flare up. I’ve come to terms with it. This is the life I was dealt and I do the best with what I got.

Ann, 42 | Methadone, 2 years, 5 years

Tapering readiness

If you think you might be ready to end treatment, ask these questions to help you decide whether to begin the tapering process:4

1. Have you been abstaining from other opioids and from illegal drugs, such as cocaine and speed?	Yes 	No 
2. Do you think you are able to cope with difficult situations without using drugs?	Yes 	No 
3. Are you employed or in school?	Yes 	No 
4. Are you staying away from people who use drugs or who are involved in illegal activities?	Yes 	No 
5. Have you gotten rid of any equipment you used to take drugs?	Yes 	No 
6. Are you living in an area that doesn’t have a lot of drug use, and are you comfortable there?	Yes 	No 
7. Are you living in a stable family relationship?	Yes 	No 
8. Do you have friends who don’t use drugs that you spend time with?	Yes 	No 
9. Do you have friends or family who would be helpful during a taper?	Yes 	No 
10. Have you been participating in counselling that has been helpful?	Yes 	No 
11. Does your counsellor think you are ready to taper?	Yes 	No 
12. Do you think you would ask for help when you were feeling bad during a taper?	Yes 	No 
13. Have you stabilized on a relatively low dose of methadone or buprenorphine?	Yes 	No 
14. Have you been on OAT for a long time?	Yes 	No 
15. Are you in good mental and physical health?	Yes 	No 
16. Do you want to stop taking OAT?	Yes 	No 

The more “yes” answers you can honestly provide, the greater the likelihood that you are ready to make a tapering plan from methadone or buprenorphine with your doctor. Each “no” response represents an area you probably need to work on to increase the odds of a successful taper and recovery.

I feel I am ready to begin to taper. I am hopeful and excited to become opiate free. I also feel scared and worried that withdrawal may be uncomfortable and that I may be at increased risk of relapse.

Courtney, 39 | Buprenorphine, 1 year

I am tapering off slowly, about 1–2 mg every couple of months, this way I don’t feel withdrawals. I feel positive.

Josée, 34 | Methadone

Methadone or buprenorphine tapering

The decision to taper off OAT should be made with the support of your doctor and counsellor, friends and family. If you’ve been on OAT for a long time, you may have stopped seeing your counsellor. Now is a good time to seek out the services of a counsellor once again. Feelings of fear and anxiety are common as you get close to the end of treatment. The risk of relapse is increased. It’s important that you prepare for the challenge by setting up a safety net of support.

Learning about what to expect throughout the tapering process can also be helpful in reducing anxiety. The more you know the less there is to be afraid of.

Tapering works best when done as a slow and gradual reduction in dose. A good rule of thumb in tapering is to decrease no more than 5–10 per cent per month.

Once the dose is lowered to around 20 mg methadone or 8 mg buprenorphine, the tapering may be slowed down to an even more gradual reduction to reduce or eliminate any symptoms. Your taper is more likely to be successful if you adjust the rate according to how you are feeling, rather than to set a fixed schedule. Nowadays, most providers will allow you to choose the rate at which your dose is reduced. This gives you more control of the process, and lets you keep withdrawal symptoms to a minimum. The entire process should be given plenty of time.

Regardless of whether you have been in agonist therapy for a short or long time, on a high or low dose, the process is the same, and the degree of difficulty in withdrawing is the same. All clients withdrawing from OAT find that the most difficult stage is at the end of the taper. This is when you are most likely to have to tolerate some symptoms of withdrawal.

Withdrawal from methadone or buprenorphine comes on more slowly and may last longer than withdrawal from opioids such as heroin or oxycodone. With tapering, the withdrawal symptoms should be minimal, but you can expect aching, insomnia and lack of appetite. These symptoms should go away within 10 to 14 days, but beyond that, you may still feel a sense of loss, sadness and sleeplessness that may go on for several months.

Relapse, or return to opioid use, is all too common at this time. It’s important to recognize the things that might trigger you to use again before it happens. You may find it helpful to identify ways of thinking that can lead you back to opioid use, and also thoughts that can help to ground you and stay on course. Some people find it helpful to stay away from old hangouts and old friends from their using days. Call on your non-using friends, family or counsellor if you’re feeling low or frustrated or stressed. Keep in mind that after you’ve been off opioids for a while, your tolerance to their effects is lowered, meaning that what used to be a normal dose is now an overdose.

Changing your mind

Keep in mind that you don’t have to go off OAT. You can change your mind and return to treatment at any point in the tapering process. Maybe you’re not ready yet, maybe you’ll be ready at a later time, maybe you’ll never be ready. Staying on methadone or buprenorphine can be the right choice for some. It’s up to you. A return to treatment is not a failure. If the choice is between being on OAT or risking a return to dangerous opioid use, stick to OAT.

After treatment ends

If you decide to go through with the taper, and you stop taking methadone or buprenorphine, it may still take a while for your body to adjust from long-term opioid use. Some people have trouble sleeping and may feel low. This can go on long after the end of the taper. During this period it is important to maintain and extend your support. Some people find that support groups can help provide the extra strength to stay firm in their decision to be drug free. Individual counselling can also help.

Recovery from addiction is not an instant fix. It takes time; it’s a process. What works for you may not work for someone else. The important thing is to find your own way, and get headed in the right direction.

4 Adapted from Tapering Readiness Inventory in Treatment of Opiate Addiction with Methadone: A Counselor Manual, U.S. Department of Health and Human Services. In S. Brummett, R. Dumontet, L. Wermuth, M. Gold, J.L. Sorensen, S. Batki, R. Dennis & R. Heaphy (1986), Methadone Maintenance to Abstinence: The Tapering Network Project Manual. San Francisco: University of California.