Like tapering off opioids with methadone, an opioid agonist taper involving buprenorphine/naloxone appears to reduce the severity of withdrawal symptoms, but most patients still relapse to opioid use if a strategy involving only withdrawal management is employed. For instance, participants in the Prescription Opioid Addiction Treatment Study demonstrated significantly lower sustained abstinence rates eight weeks after tapering off buprenorphine/naloxone (8.6%) compared to abstinence rates during buprenorphine/naloxone treatment (49.2%).305 A 2018 single-site randomized controlled trial demonstrated that participants who were linked to ongoing buprenorphine/naloxone maintenance treatment following a buprenorphine/naloxone-managed withdrawal protocol reported significantly lower rates of unregulated opioid use after 3 months compared to those who were not linked to maintenance treatment.306

Buprenorphine may offer some advantages over methadone when used during a taper, specifically offering faster symptom relief.235 There does not appear to be a significant difference in terms of withdrawal symptom severity,235 withdrawal treatment completion (RR:1.04, 95% CI: 0.91–1.20), or average treatment duration (mean difference [MD]: 1.30 days, 95% CI: -8.11–10.72)307 for individuals managed with buprenorphine compared to methadone.235

Compared to alpha2-adrenergic agonists, buprenorphine appears to offer more effective relief of withdrawal symptoms, as indicated by the lower overall withdrawal score (standardized mean difference [SMD]: -0.43, 95% CI: -0.58 to -0.28), longer retention in treatment (SMD: 0.92, 95% CI: 0.57–1.27) and greater likelihood of completing treatment (RR 1.59, 95% CI 1.23–2.06).307 There does not appear to be a significant difference between buprenorphine and alpha2-adrenergic agonists in adverse effects (RR 0.93, 95% CI 0.70–1.26),307 except in comparison with clonidine, which is associated with higher rates of drop-out due to side effects.235