Where do cravings come from when you are on Suboxone?
Where does a craving come from? Why, months into treatment, does the thought of using show up on an ordinary afternoon, and why does it feel so convincing? The answer is in triggers.
An external trigger is a person, a place, a smell, or a thing that brings back the memory of using. An internal trigger is a feeling, a thought, or a memory that does the same job from the inside.
Suboxone, and I use that name here the way most patients do, to mean any buprenorphine medication for opioid addiction, takes away most of the daily pull. Yet, medication does not erase memory, and the brain learned over years that a certain corner or a certain feeling comes right before the drug.
Taking buprenorphine every day does make you physically dependent on it, and that is not addiction. Dependence is what your body does with any daily medication, and the craving that ambushes you on an ordinary afternoon is the addiction, which is why the two are treated differently.
A craving on buprenorphine is not a sign that the treatment has failed, and it is not a sign that you have. It is a signal that a trigger has been pulled. So, what do you do with it?
What is an external trigger?
The gas station where you used to meet your dealer is an external trigger, and so is a song, or a friend from that time. Smells are surprisingly powerful, because the sense of smell has a direct line to emotional memory. Patients have described the lavender scent in ordinary soaps and lotions bringing on a craving years later, because that smell was somehow in the room when they used. I cannot tell you why lavender and not the dozen other things in that room, and it does not matter, because the brain decided without asking.
Fortunately, while you cannot control what the world puts in front of you, many external triggers can be avoided. If the corner store on your old route triggers you, take a different route, and if there is no other route, at least know what is coming before you pass it.
You cannot remove every external trigger from your life. You can remove the ones that matter most.
Should I delete my drug dealer’s phone number?
Does the answer seem obvious? It should be, yet people find remarkable reasons to hold on to the one connection that can undo everything.
Patients have explained to me, after a drug test came back positive for fentanyl and negative for heroin, that they needed to go warn the dealer, who surely believed he was selling pure heroin. For a moment, the reasoning almost makes sense. Wouldn’t it be a public service to warn him?
The answer is no. The dealer almost certainly knows what he is selling, and the only guaranteed result of that visit is you, standing in front of your dealer with a good story. When I hear this kind of reasoning, my job is to name it out loud, because from the inside it sounds exactly like a reason.
So, delete the number, the contact record, the social media connection, and every other path back. The goal is to no longer know where to buy, because a craving lasts minutes and finding a new connection takes much longer. The craving passes first.
How do internal triggers differ from external triggers?
Internal triggers come from inside, and you can avoid every gas station in the county and still be ambushed by a feeling. Painful feelings certainly do it, because many people started using opioids to muffle emotional pain, and when that pain returns, the old solution returns with it.
Yet, good feelings trigger cravings too. Boredom on a Saturday afternoon, a raise at work, a party where everyone is relaxed and happy, any of these can bring up the thought that this would be a fine moment to use.
Unfortunately, you cannot delete a feeling the way you delete a phone number. Internal triggers have to be lived with, and the rest of this article is about how.
Cravings are thoughts, and thoughts can lie.
Early in treatment, the frightening part is that you cannot fully trust your own thinking. There is one reliable test. Any line of reasoning that ends with you using is the line of reasoning not to trust, no matter how sensible the steps in the middle appear.
So, when a craving arrives, the best first move is to do nothing. Notice the thought, name it as a craving, and take no action, because a craving usually peaks and passes in a matter of minutes.
Then, call someone you trust and say out loud what just happened. Saying it out loud takes most of the power out of it. A craving kept secret keeps all of its power, and it will use it.
Why is a relapse after months away the dangerous one?
Unfortunately, when you have been off of opioids for a while, your tolerance is gone. A dose you once used every day can now stop your breathing.
Much of what is sold as heroin or as pain pills today is fentanyl or contains it, so there is no such thing as a careful test run. “Just one more time” is how many fatal relapses begin, and the person never planned to die.
While you are taking your buprenorphine every day, it is sitting on the receptors and blunting the effect of other opioids, and that is real protection. I also ask every patient to keep Narcan (naloxone) at home and to tell the people around them where it is. The nasal spray is sold over the counter, and it reverses an opioid overdose long enough to get help, so if someone cannot be woken or is breathing slowly after using, call 911 and give the naloxone.
And, if you do relapse, it is never too late to stop again. Call your doctor the same day, because a relapse during buprenorphine treatment is a medical event to manage, not a verdict on you.
What changes after a year, and what does not?
While people in recovery talk about the one-year mark as if a switch flips, there is no magic date. Somewhere in the first year or two, for most patients, the cravings thin out, and when a thought of using does come, fear of the consequences outweighs the memory of the high. For some it comes sooner, for some it takes a good deal longer, and in my experience the odds of staying stopped keep improving the longer you stay stopped.
Do not try to see a year ahead in your first week. The part of your brain that wants to use will happily use the size of that number against you, so count today, and let the days add up on their own.
Accumulated time off of opioids is a possession of real value, and a relapse spends it in an instant. Treasure it.
What are the warning signs that a relapse is coming?
The warning signs usually show up before the drug does. A number kept “just in case,” a drive past the old corner for no reason, a craving kept secret, a skipped dose of buprenorphine because you felt fine that day, each of these is a decision that can still be reversed.
If you have relapsed before, you already own a set of data that no doctor can give you. Go through it honestly, without the shame, and you will usually find that the relapse began well before the drug, at a number not deleted or a route not changed. That is not proof that you are hopeless. It is a map of where your walls need to be.
Addiction is like driving a car with failed brakes.
An analogy that might help is a car with failed brakes, parked at the top of a hill. The first time you drove it down, you did not know the brakes were gone, and that first ride was not your fault.
Now you know. Every ride after that begins with the same fun first few seconds, and it ends the same way. Halfway down the hill, there is nothing left to decide. The only decision you still own is whether to get in the car.
While this is not a perfect analogy, it says something true about opioid addiction. Willpower halfway down the hill is a poor plan, and every practical decision in this article, the deleted number, the changed route, the phone call, is made at the top. Buprenorphine is how the brakes get repaired, so the decision is no longer willpower alone.
Can tramadol, kratom, or a surgery bring the craving back?
Yes. Tramadol, sold as Ultram, is an opioid, even though it is often prescribed as if it were a mild alternative, and kratom is a plant product whose active compounds act on the same opioid receptors. Either one can wake the old pathway.
So, tell every doctor and dentist who might write you a prescription that you take buprenorphine, and do not accept tramadol as a compromise. If a pain medication is truly needed, that decision belongs in a conversation between you, the prescriber, and your buprenorphine doctor.
Patients ask what happens if they need emergency surgery. This is a good question. Surgery and anesthesia can be managed while you are on buprenorphine, and the usual practice now is to continue it through the procedure. Tell the surgeon and the anesthesiologist, and if there is time, have them speak with your buprenorphine doctor.
Never stop buprenorphine on your own because a surgery is coming. Stopping it opens the door that the medication was holding shut, right when a hospital is about to hand you opioids.
Should I go to Narcotics Anonymous meetings while I am on buprenorphine?
While meetings help many people, and I would not discourage anyone from going, a patient on buprenorphine or methadone should know before walking in that some groups do not consider them abstinent and may limit what they can share. Officially, Narcotics Anonymous does not turn anyone away for taking a medication, yet the reception varies from room to room, and patients have described being told, in a meeting, that they were not really in recovery.
If that happens, it is the room, not you. Find another meeting, or another kind of group, and keep your medical treatment where it belongs, between you and your doctor. There is more in Narcotics Anonymous: should you go to meetings?
What does buprenorphine treatment by telemedicine do about cravings?
Dr. Leeds provides buprenorphine treatment for opioid addiction by telemedicine to patients throughout Florida, with in-office visits available in Fort Lauderdale. Induction is done at home with phone support, with a low-dose induction when fentanyl is involved, and cravings and triggers are talked through as part of every medical visit, not in a separate program and with no mandatory meetings. There is no “aftercare” program to graduate into, because ongoing treatment with a physician is the aftercare.
To ask about buprenorphine treatment by telemedicine, contact Dr. Leeds.
Call 911 or go to the nearest emergency room if someone cannot be woken, is breathing slowly or not at all, or has blue lips or fingertips after using opioids, and give naloxone if you have it. If you are having thoughts of ending your life, call or text 988 to reach the 988 Suicide & Crisis Lifeline, or go to the nearest emergency room.
This article is educational. It is not medical advice, and reading it does not create a doctor-patient relationship. Decisions about starting, continuing, or tapering any medication should be made with your own physician.
