Why Precipitated Withdrawals Happen
- When opioids (like heroin or oxycodone) are used over a period of time, the brain becomes dependent.
- Buprenorphine (the main ingredient in Suboxone) is a patient opioid and has a stronger bond to the same opioid receptors in the brain.
- When Suboxone is taken too early, it pushes the full opioids off the receptors leading to sudden and usually severe withdrawal symptoms.
People with higher levels of physical dependence and those coming off long-acting opioids like methadone may be more likely to experience precipitated withdrawals.
Precipitated Withdrawals From Buprenorphine-Only Medication
The secondary ingredient in Suboxone is Naloxone. Naloxone is not what causes the withdrawals when Suboxone is taken orally. Buprenorphine-only medication will still cause precipitated withdrawals if taken too soon after opioid use.
Precipitated Withdrawals From Injecting Suboxone
With normal use, the naloxone generally doesn’t get absorbed in the bloodstream. But, if Suboxone is injected, the Naloxone is activated and can cause precipitated withdrawals.
Naloxone is the same ingredient in Narcan. The medication acts on the brain’s opioid receptors to knock off and block any opioids that are present. The abrupt removal of opioids from the receptors can also cause precipitated withdrawal symptoms. ⓘ
The Symptoms of Precipitated Withdrawal from Suboxone
The symptoms of taking Suboxone too early after drug use are the same as opioid withdrawal, although usually more immediate and intense, including:
- Anxiety, restlessness or irritability
- Body aches and pains
- Fever and sweating
- Rapid heart rate
- Nausea, vomiting and diarrhea
- Tremors
- Emotional distress
The symptoms and intensity of precipitated withdrawals are different for each person, based on factors like the type, amount and timing of opioids used, the individual’s metabolism and their level of opioid dependence.
What Precipitated Withdrawal Is Like
Precipitated withdrawals are usually described as an intense and distressing experience that is similar to, but worse than regular opioid withdrawal.
"After 20 minutes, my stomach began to hurt and I had to rush to the bathroom. I felt the MOST INTENSE chills and started sweating profusely at the same time. I also felt nauseous. Then, my mind started to slip. It was like a distressing psychedelic trip where I lost touch with reality. Oxycodone and benzos didn’t help. It was only after two hours that the effects gradually subsided and eventually I managed to sleep. I woke up six hours later and felt mostly normal. This was far more horrifying than any opioid withdrawal I've previously experienced."
The worst of it for me was I was having the most intense hot and cold flashes and restless leg syndrome. But, I made it through, and you can too! On day 4, I felt the best I ever did. Subs saved my life.
What To Do If Experiencing Precipitated Withdrawal from Suboxone
1. Seek Help
If you have taken Suboxone without medical supervision and are experiencing symptoms of precipitated withdrawal, going to a Suboxone clinic or hospital will help manage the unpleasantness and prevent relapse.
For example, medications like Ondansetron help manage nausea and vomiting. NSAIDs like ibuprofen help manage pain and fever. Loperamide helps manage diarrhea. Staying hydrated is also important during precipitated withdrawal to prevent complications.
2. Do Not Take More Opioids
Taking more opioids does not help like with normal opioid withdrawal and overdose is much more likely.
Suboxone bonds stronger to the receptors in the brain than other opioids. Opioids taken while in precipitated withdrawal will not be able to attach to the receptors to provide relief like with normal opioid withdrawal. People often take more and more opioids to try to get relief. But, sadly, overdose is more likely than a cure by taking opioids in precipitated withdrawal.
Taking more Suboxone also makes symptoms worse because more opioids get knocked off the receptors.
How Suboxone Impacts Precipitated Withdrawal Symptoms
3. Give Yourself Time
Time is often the only thing that can cure precipitated withdrawals. The good news is that intense precipitated withdrawal symptoms tend to resolve in a matter of hours, not days or weeks like other opioid withdrawals.
See also: How Long Does Withdrawal Last
How To Prevent Precipitated Withdrawals When Taking Suboxone
A healthcare provider considers each patient’s overall health, individual metabolism, drug tolerance, and both the amount and type of substance last used in addition to the general guidelines below to prevent precipitated withdrawals.
Wait For Signs Of Withdrawal
Before starting Suboxone, the patient should be in a state of opioid withdrawal. This helps ensure other opioids are no longer significantly occupying the brain’s opioid receptors.
Exact timing depends on the opioid.
- Short-acting opioids like heroin or prescription painkillers may require 12 to 24 hours from their last dose.
- Longer-acting opioids like methadone might be more like 24 to 48 hours or longer.
Remember, if you hold out initially, the withdrawal symptoms will be helped by Suboxone. But, if you take it too early, only time and comfort medications can help symptoms.
Use The Clinical Opiate Withdrawal Scale (COWS)
Medical professionals use the Clinical Opiate Withdrawal Scale (COWS) to measure the severity of withdrawal symptoms. Patients should not take Suboxone until scoring at least 8-10 on COWS, which indicates mild withdrawal. To better prevent precipitated withdrawal, patients may wait until reaching moderate withdrawal with a score of 13+. ⓘ
Start With A Low Dose
Healthcare providers start with a lower dose of Suboxone and then gradually increase the dose over time, which also helps minimize the risk of precipitated withdrawal. ⓘ
See Suboxone Dose article
Go To a Suboxone Clinic
Precipitated withdrawals rarely happen at a Suboxone clinic. Starting the medication at a clinic means a medical team with specific experience does all the work to monitor vitals and withdrawal symptoms to ensure proper timing. They are also there to support you to stay on track in the first few days and weeks of treatment.
Read more: What is a Suboxone Clinic?
If you’re in Illinois or Texas, here are Symetria’s 5-star Google-rated clinic:
Avoid Precipitated Withdrawals from Suboxone
If the clinics are not near you, visit SAMHSA’s Buprenorphine Treatment Provider tool.
39 Comments
Why is it so difficult to get off small doses of Suboxone? I tried to go cold turkey from 4 mg a day, and I just had nothing but withdrawal for seven days and no relief. I finally just took more Suboxone and gave up the idea of quitting.
It is common to experience difficulty tapering fully off Suboxone, more so if you have been on the medication for several years. Your brain is dependent on the medication, so if you take it away you will feel withdrawal symptoms. Your brain needs time to adjust to the lack of opioid in your system. The last couple of milligrams are always the toughest! The best ways to taper off of it and reduce risk and severity of withdrawal is to taper more gradually over a period of many months. For example, instead of decreasing from 4 mg daily to 0 mg, try decreasing to 2mg daily and stay at that dose for a full month before deciding to decrease further. If you have the sublingual film version of the Suboxone, the films can be easily cut to make dose adjustments even smaller if needed. If you continue to experience opioid withdrawal symptoms despite minimal dose adjustments, then your medical provider may be able to prescribe you comfort medications to help reduce the intensity of the opioid withdrawal symptoms.
The VA told me that they are willing to give me a Suboxone shot in the stomach like insulin. They said normally it last one month and then they will re-administer another shot. They said, though, if I want to stop, then they simply don’t give me another shot and that’s it. Supposedly that’s all I need to be able to go off of Suboxone. This sounds a little sketchy to me. Is it true that I can be able to walk away from Suboxone after one shot?
Yes. That is true. The reason behind this is that the medication will still be present and having an effect in your body for a couple of months after the injection. The amount in your blood stream will slowly decrease over that time. Since the decrease is so gradual over a few months, this causes a natural taper effect that gives your body ample time to adjust. Therefore, it is uncommon to experience opioid withdrawal symptoms after stopping the injection, even after only one injection.
So today I waited 18 hours after taking my last wet line last night and thought I was ready to take suboxone today. So I did heroin at 8:45 pm last night and today at 2:30 pm I thought I was withdrawing enough so I took 4mg orally (sublingual)and waited about an hour, didn’t feel worse or better so took more 4 more mg. But I guess not. After the second 4 mg I knew what was happening pretty quickly. Precipitated withdrawal. This Suboxone was dispensed in 2021. Did I only dose naloxone. Cause I heard buprenorphine goes bad after one year storage. It’s now 10:57 pm and I feel like dog shit still. I haven’t taken more of anything! Proud of myself. But how long will this go for now? And when it’s over will all opiates be gone and no more withdrawal? Can I just stop talking everything then?
The naloxone portion of the Suboxone is very minimally absorbed when taken sublingually, not enough to cause any withdrawal. Even though the Suboxone is technically expired, it would still work about 80% as well as Suboxone that is not expired. I’m sorry you’re having a rough experience with the Suboxone. The more intense withdrawal symptoms should resolve within 24-48 hours. The physical symptoms of opioid withdrawal can last anywhere from 5 to 14 days. If you were using large amounts of fentanyl over a period of months, then the fentanyl may still stay in your system even up to 4 weeks from the last use. Otherwise, all of the opioids should be out of your system completely by 14 days from the last use. You will have a much greater chance of successfully maintaining abstinence from illicit opioids if you engage in counseling and/or medication for addiction treatment (MAT) such as Suboxone or methadone. Detoxing alone is not very effective because the brain hasn’t had time to heal, cravings can still remain, and you haven’t had time to change other behaviors and habits around your substance use.
Will Subutex cause precipitated withdrawal?
Subutex (or the generic version buprenorphine) can only cause precipitated withdrawal if it is taken before you are in enough opioid withdrawal. If Fentanyl is being used, I recommend waiting as long as possible (at least 24 hours, but preferably longer, since your last use of Fentanyl) before starting Subutex. This will drastically reduce the risk of you developing precipitated withdrawal.
My boyfriend is in precipitated withdrawal. I took the same Subutex and I am not in withdrawal. I feel fine. He is shaking and miserable. Do I give him another sub?
If you feel there is precipitated withdrawal, it is usually best to continue with the Subutex. It is not recommended to stop buprenorphine induction or resort to other opioids (like oxycodone or fentanyl) to try to remedy the discomfort. What will help is to provide additional Subutex up to a maximum of 24mg in a 24 hour period, while also using other comfort medications (Benadryl for anxiety or difficulty sleeping, Ibuprofen for aches and pains, Imodium AD for diarrhea).