How to Prevent Precipitated Withdrawal from Suboxone

Withdrawal from opioids can be very uncomfortable. When a person dependent on opioids discontinues or a severely reduces their opioid dose they can develop anxiety, tremor, cold sweats, muscle aches, joint pains, nausea, vomiting, diarrhea, abdominal cramps, watery eyes and nose, sneezing, yawning, and insomnia. The threat of withdrawal drives many people to keep using opioids, even if they no longer experience a high from opioid use due to tolerance.

“Precipitated withdrawal” is a medical term that describes the severe distress that can occur if a person with opioid dependence takes a medication that blocks the action of opioids while there are still mu-agonist opioids in the body (mu-agonist opioid are drugs which provide a high level of stimulation to opioid receptors in the body like heroin or fentanyl). As described in my “How Does Suboxone Work?” blog post, buprenorphine (the active ingredient in Suboxone) is a partial mu-agonist, which means that it only partially stimulates the opioid mu-receptors, and it also binds to these receptors more strongly than most other opioids. These means that when a person takes buprenorphine, it rapidly displaces all other opioids from the mu-receptors and the person goes from a high level of mu receptor stimulation to a lower level.

This rapid drop in the level of mu receptor stimulation results in the development of opioid withdrawal symptoms. These symptoms are typically more severe than standard withdrawal symptoms because of the speed at which the mu-receptors go from fully stimulated to only partially stimulated. Precipitated withdrawal also occurs when Narcan (naloxone) is given to reverse an overdose.

Taking more Suboxone will not reverse precipitated withdrawal, as even a small dose results in nearly all mu receptors being occupied with buprenorphine. Conversely, precipitated withdrawal cannot be treated by taking additional doses of another opioid, like heroin or fentanyl, because these drugs do not bind to the mu-receptors as strongly as buprenorphine does.

The naloxone component of Suboxone does not produce precipitated withdrawal. It cannot, because buprenorphine binds more strongly to mu-receptors than naloxone does. Therefore switching Suboxone to Subutex does not prevent precipitated withdrawal.

The only method to stop precipitated withdrawal is to wait. With time, the body will become acclimated to the lower level of mu-receptor stimulation and the symptoms will subside. Typically the symptoms will abate by the time the next dose of Suboxone is due.

Suboxone Withdrawal Treatment

The best treatment for precipitated withdrawal is prevention. It can be prevented by carefully timing the first dose of Suboxone and only taking this first dose after the patient has developed actual withdrawal symptoms. This means waiting at least 12 hours after the last dose of short acting opioids and at least 48 hours after the last dose of long-acting opioids. These are minimal wait times, however, and Suboxone should not be given to a person who is not experiencing actual symptoms of withdrawal, even if it has been 12 hours from their last dose of short acting opioids and 48 hours after their last dose of long-acting opioids.

Withdrawal symptom severity can be calculated using a clinical scoring system called “COWS” (Clinical Opioid Withdrawal Score). A patient should have a COWS of at least 5 or higher before taking the first dose of Suboxone in order to prevent precipitated withdrawal. Best would be to wait until the score is 10 or higher, as the risk of precipitated withdrawal is lower still. COWS can be scored by the patient themselves (so long as they can count their pulse and can accurately guage their subjective symptoms), but it is best for the COWS to be calculated by an outside observer, such as a doctor or nurse, to reduce error.

If you are attempting to induce yourself on Suboxone at home, use discretion in scoring your withdrawal symptoms. If you are unsure how severe your symptoms are, it is best to err on the side of the lower number when calculating COWS. If you are not sure if you are in withdrawal yet, it is better to wait another hour or two and then reassess. Remember that once you have taken a dose of Suboxone, you are unable to remove the buprenorphine from your system. A hours of mild withdrawal symptoms is better than 12 hours of miserable intense precipitated withdrawal.

Some opioids make Suboxone induction more difficult because they persist for a long period in the human body. These drugs are methadone and fentanyl.

Methadone has a very long half life in the human body of 24-36 hours; since it takes about five half lives for a drug to be 99% eliminated, this means that it can take 5-7 days after your last dose before the methadone is gone and it is safe to take your induction dose of Suboxone. Transitioning from methadone to Suboxone is therefore quite difficult and best done under direct care of a trained physician.

Fentanyl, on the other hand, is actually very short acting in the body with a half life of about 15 minutes, but it can accumulate in body fat with prolonged use. This is called a “depot effect” (think of a warehouse or “depot” being filled with merchandise which is slowly distributed out). The fentanyl and fentanyl metabolites in body fat can take days or even a week to fully leave the body in a person who has been using fentanyl for a prolonged time. The length of this depot effect varies depending on the size of the patient, their body fat percentage, their metabolism, the length of their fentanyl use, and the average daily amount of fentanyl used. This means that even though fentanyl is a short acting opioid, it can act like a long-acting opioid with prolonged use.

There are two strategies that can be used to help patients taking methadone or fentanyl during their induction to Suboxone.

The first is simply waiting until all the methadone or fentanyl has been metabolized and only then giving the induction dose of Suboxone. If desired, the symptoms of withdrawal during the waiting period can be treated with non-opioid drugs, such as gabapentin, clonidine, ondansetron, ibuprofen, and loperamide. Masking withdrawal signs with drugs may make induction timing more difficult to predict, however, so care must be taken when timing the first dose.

The second strategy is known as microdose induction. The idea is to slowly raise the level of buprenorphine in the blood stream while the level of methadone or fentanyl falls. This is achieved by taking small doses of Suboxone starting about 24 hours after the last dose of methadone or fentanyl and then taking escalating doses at increasing frequency until a stable daily dose is achieved. If done properly, the patient should experience minimal or no withdrawal symptoms.

If you or someone you love is suffering from problematic drug or alcohol addiction use and is seeking treatment, contact the clinic by calling or clicking the “Get Started” button in order to schedule a discovery call and initial evaluation, both of which are free.

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North Tampa Executive Health Clinic is directed by Dr. Jack McGeachy. He provides confidential and comfortable addiction treatments and therapy for opioid and alcohol use disorder. Rather than a rehab or detox, meaning that each patient is cared for one-on-one by a medical doctor, in contrast to other treatment programs. Heed Help? Book your in office appointment in the Tampa office or via video conferencing today.

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