The rule of thumb is that you’ll be able to wean 80% of patients off of buprenorphine after one year without too much difficulty. Of the remaining 20%, some(~10%) you will be able to wean off with more difficulty, i.e. requiring adjuvant medications, and some (~10%) you will not be able to wean off completely. Over the years, those “unweanable” patients will fill your buprenorphine slots.
I consider these based on the symptoms. I look at their patient/family history to see what has worked for them in the past. As an example, I may use mirtazepine for anxiety and sleep. It has a good sedating effect and if the patient has underlying anxiety it can to help. I may use clonidine if there are withdrawal symptoms. If they are on clonidine for over a week you should not discontinue abruptly but rather do a gradual taper mainly to avoid rebound increase in blood pressure.
