Your provider might tell you that you have to wait to start your medication to avoid precipitated withdrawal. What is precipitated withdrawal, and why does it matter?
Medications like buprenorphine have drastically revolutionized the treatment of opioid use disorder, improving access to treatment, and can be prescribed for home use. However, as with any medication, there are unique considerations when starting buprenorphine to avoid side effects like precipitated withdrawal.
This blog provides a brief overview of medication-assisted treatment, precipitated withdrawal, and tips to cope with starting buprenorphine.
What is precipitated withdrawal?
Most people who use opioids are familiar with some withdrawal symptoms or dope sickness. When these symptoms start on their own because the opioids are wearing off, that’s called “spontaneous withdrawal.” Spontaneous withdrawal starts at a lower intensity, gets worse over time, and then eventually gets better.
Instead of starting on its own, “precipitated withdrawal” is precipitated, or set off, by something else. With opioids, that usually happens because another substance is binding to and blocking the opioid receptors in the brain, keeping opioids from having an effect. It can happen with the rescue medicine naloxone (Narcan), with the opioid antagonist naltrexone, and with buprenorphine if you have other opioids still in your system when you take it. With precipitated withdrawal, the symptoms are intense right from the start.
Precipitated withdrawal symptoms may include:
- Aches
- Nausea
- Vomiting
- Diarrhea
- Abdominal cramps
- Bone and muscle pain
- Anxiety
- Insomnia
- Muscle spasms
- Runny nose
- Sweating
- Yawning
- High blood pressure
But the good news is that precipitated withdrawal can often be prevented. And if it happens, it can be treated.
What is medication for opioid use disorder?
Medication for opioid use disorder is the use of medications like buprenorphine, methadone, and extended-release naltrexone in combination with behavioral therapies to treat opioid use disorder. Medication for opioid use disorder is endorsed by the National Institute on Drug Abuse (NIDA) and the Substance Abuse and Mental Health Services Administration (SAMHSA) as the gold standard of treatment for opioid use disorder. Yet, medication for opioid use disorder is drastically underutilized.
According to the Centers for Disease Control and Prevention (CDC), there is a lack of communication about the effectiveness of these medications, and providers are markedly underusing them.
There are some misconceptions about medication for opioid use disorder, like the belief that you are swapping one addiction for another. However, this feeds into the lack of communication about how these medications work and their effectiveness.
Suboxone is an evidence-based medication approved by the Food and Drug Administration in 2022 as a safe and effective form of medication-assisted treatment. The active ingredient in this medication is buprenorphine, which is a partial opioid agonist that partially binds to the brain’s opioid receptors, thus limiting its effects compared to full opioid agonists like heroin.
Suboxone reduces withdrawal symptoms and cravings and blocks the effects of other opioids. Medication for opioid use disorder lowers the risk of transmitting infectious diseases, reduces the risk of death, reduces opioid use, improves employment opportunities, increases the risk of remaining in recovery, and reduces criminal justice involvement in substance use.
When can I start taking buprenorphine to avoid precipitated withdrawal?
The answer depends on the type of opioid you have been using and for how long.
Guidelines for medication for opioid use disorder induction recommend waiting at least 8 hours after using opioids before starting buprenorphine. However, this depends on each person and the type of opioid they use. Typically, this can take 12 to 24 hours. But chronic use of fentanyl may lead to precipitated withdrawal even after waiting 8 to 24 hours before starting buprenorphine. However, research shows the risk of precipitated withdrawal is low.
NIDA recently highlighted a multi-site National Institute of Health study that showed that the risk of precipitated withdrawal in individuals with opioid use disorder who use fentanyl may be as low as 1 percent, and starting buprenorphine in the ER is still found to be safe and effective.
Typically, a person must be in some kind of opioid withdrawal before starting buprenorphine, and this usually takes 12-24 hours after their last use of an opioid. Some providers use an approach called buprenorphine micro-induction (or ultra low dose start) that involves taking small and increasing doses of buprenorphine to avoid precipitated withdrawal. However, a medical provider can determine the right course of treatment for each person.
How to cope with withdrawal symptoms
While uncomfortable, it is possible to manage withdrawal symptoms by knowing what to expect and having a plan in place. You can make yourself more comfortable by following some of these tips:
- Speaking to a substance use professional and having a treatment plan in place.
- Drink lots of water and replenish electrolytes.
- Use showers or baths to cope with changes in body temperature.
- Have a list of distractions ready, like your favorite show, music, a project to tackle, or your favorite book.
- Keep in touch with your medical and behavioral health provider for support.
- Remember your why: Knowing your reasons for recovery and writing them down can be a great reminder that these symptoms are temporary and part of a bigger goal to improve your health and well-being.
Talk with your medical provider about your concerns; they may recommend medications to help reduce withdrawal symptoms while you are waiting to start buprenorphine.
What if I do develop precipitated withdrawal?
When you’re in precipitated withdrawal from opioids, what you really want to know is how to cope. Your provider may recommend that you:
- Take additional buprenorphine
- If withdrawal symptoms start, your provider may suggest you take another 8–16 mg of buprenorphine.
- Wait about an hour before considering another dose. Repeat as needed until your symptoms are relieved (as guided by your provider).
- Use comfort medications
- Your provider may suggest medications (over-the-counter or prescription) to help relieve symptoms like:
- Muscle aches (treated with medications such as acetaminophen (Tylenol) or ibuprofen (Advil))
- Diarrhea (treated with medication such as loperamide (Immodium), taken only as directed)
- Nausea (treated with medication such as ondansetron (Zofran) or bismuth subsalicylate (Pepto-Bismol)
- Restlessness or trouble sleeping (treated with medication such as melatonin, trazodone, clonidine, or lofexidine)
- Your provider may suggest medications (over-the-counter or prescription) to help relieve symptoms like:
- Stay hydrated and rest
- Drink water or clear fluids.
- Rest in a comfortable position to help your body cope with symptoms.
- Monitor symptoms
- Keep track of how you feel (maybe by making notes or recording quick snippets on your phone).
- Contact your healthcare provider if your symptoms get worse or if new, concerning symptoms appear.
- Avoid other opioids, depressants, alcohol, or stimulants
- You may be tempted to take additional opioids to relieve your symptoms. Don’t do it! It can make you feel worse, increase your risk of overdose, and put you right back into the cycle of opioid use and dopsesickness. Taking other substances is also dangerous.
When your provider recommends that you begin buprenorphine, they will discuss what you should watch out for and when you should go to the emergency department. The warning signs will usually include severe agitation or confusion, difficulty breathing, chest pain, dizziness, dehydration, or difficulty keeping down food/liquids. If you have trouble remembering your provider’s instructions, ask for notes that you can review later to remind you.