By Dr. Leeds, osteopathic physician and deprescribing specialist, with over two decades of experience in treating medication and drug dependence and addiction, including opioid dependence with buprenorphine.
Why does Suboxone make your feet and legs swell?
Have you noticed since starting Suboxone treatment that your ankles and feet seem to be a bit swollen? What does it mean? Could it be the Suboxone causing it? The short answer is yes, it could be, and it is one of the more common complaints I hear from patients on buprenorphine.
Swelling around the ankles is called edema, and patients often call it water retention. Edema is fluid that has left the bloodstream and collected in the soft tissues around your ankles and feet.
Why does this type of swelling most often happen around the ankles? Because of gravity. People spend most of the day with their feet below the level of the heart, and the feet and ankles are the parts of the body furthest from it. So, it takes more work to get blood back up through the veins, and when fluid leaks out along the way, the lowest point is where it collects.
Suboxone can cause it. In fact, the Suboxone prescribing information lists peripheral edema, meaning swelling of the feet, ankles, and lower legs, among the most frequently reported side effects since the medication came to market. So, is it serious, and what should you do about it?
Is ankle swelling serious?
Ankle swelling can be a serious symptom. Some of the more ominous causes of edema are problems with the heart, the liver, or the kidneys, and a swollen leg can also be a blood clot. There are less serious causes as well, including medication side effects, and most of the swelling I see in Suboxone patients falls into that group.
While the swelling itself is usually mild, nobody can tell the mild kind from the serious kind by reading about it. Your doctor tells them apart by examining you, asking about your other medications, and sometimes ordering a few blood tests. That is why my rule is simple: usually minor, always evaluated.
In my experience, Suboxone swelling is dose-related. It tends to show up in the first weeks or months of treatment or after a dose increase, and it often improves after the prescriber adjusts the dose. I say the prescriber, because the adjustment is a medical decision and not a home experiment.
Some swelling is not a Suboxone side effect at all, and it needs to be seen right away. Call 911 or go to the nearest emergency department if you have:
- Swelling of the face, lips, tongue, or throat, or any trouble breathing or swallowing.
- Chest pain, shortness of breath, or trouble breathing when you lie flat.
- Sudden swelling in one calf that is painful, warm, or red, especially if it came on over hours rather than weeks.
- Rapid weight gain of several pounds over a few days along with the swelling.
Do not let the fact that you take Suboxone talk you out of an emergency visit. The medication does not make any of these symptoms less urgent.
What does Suboxone swelling look like?
Patients usually notice it at the end of the day. Socks leave a deep ring around the ankle, shoes that fit in the morning feel tight by evening, and the tops of the feet look puffy. The legs may feel heavy or achy after a day of standing, and sometimes the hands puff up as well.
If you press a thumb into the swelling and the dent stays after you let go, that is pitting edema, which is what medication-related swelling usually looks like. Your doctor will do the same thing, which is one reason a hands-on examination matters.
And, the scale may move too. A few pounds of fluid can show up as weight gain that has nothing to do with fat, and patients who ask whether Suboxone causes weight gain are sometimes describing exactly this.
A pattern I have seen many times is the patient who is doing well on buprenorphine and mentions the sock rings almost as an afterthought, half expecting me to say it is nothing. It is a side effect worth a conversation, and the conversation usually ends with a small change in the dose or a hard look at the rest of the medication list. It is not nothing.
How does Suboxone cause ankle swelling?
Keep in mind that Suboxone contains an opioid, buprenorphine. While bupe is a partial opioid that activates the receptor only part of the way, it can still cause the side effects that other opioids cause, and fluid retention is one of them.
Yet, why opioids cause edema is another matter. Nobody is completely sure. One theory involves antidiuretic hormone, the hormone that tells the kidneys to hold on to water, although studies of what opioids do to that hormone point in different directions. There are other theories, and none of them has been proven.
The internet is more confident than the label. Nearly every article on the subject explains the mechanism in a tidy paragraph, and the people who wrote the prescribing information declined to explain it at all. I do not know why buprenorphine makes ankles swell, and I am suspicious of anyone who says they do.
What I do know comes from watching patients. The swelling tracks the dose, it is more common at higher doses, and it usually gets better when the dose comes down. That is not a mechanism. Yet, it is enough for you and your doctor to act on.
Do I have to see my doctor about Suboxone swelling?
Yes. Just because you know that ankle swelling is a common side effect of Suboxone, and you know that adjusting the dose may help, does not mean you should handle it on your own. First, your doctor must be involved in any decision to change your Suboxone dose. Second, your doctor will also assess you for the more serious causes of edema.
While a lower dose may well fix the ankle, a dose that is too low invites withdrawal and cravings, and that is a much larger problem than a swollen ankle. Your doctor can lower the dose in steps, watch what happens, and go back up if the trade is not worth it.
Whenever you notice an adverse event during medical therapy, you must let your doctor know what is going on. Your doctor wants to hear from you if you have any problems, so do not worry about being a nuisance.
Can a telemedicine doctor evaluate a swollen ankle?
If you see your doctor by telemedicine, showing them a swollen ankle is a little harder than it sounds. You can aim your phone camera at your ankle and get a decent picture. Yet, a camera cannot press on the swelling, mild puffiness and serious swelling can look about the same on a phone screen, and sometimes the doctor needs to feel it with their own hands.
Fortunately, there are ways to get the in-person look. Your telemedicine doctor may work with doctors who see patients in the office, or may send you to an urgent care center for an examination and a few labs. And, if the swelling is sudden, one-sided, painful, or comes with any of the emergency symptoms above, the emergency department is the right place, not a video visit. I would rather order an examination that proves unnecessary than miss a clot.
Are there other kinds of medications that cause ankle swelling?
Suboxone is definitely not the only medication that can cause edema, and a swollen ankle is often a group effort. There is a class of high blood pressure drugs known for swollen ankles, the calcium-channel blockers, and Norvasc, or amlodipine, is the one I see most often on medication lists. Swollen ankles are its best-known side effect, and the higher the dose, the more common they are.
Another class of drugs that can cause edema is the NSAIDs, or non-steroidal anti-inflammatory drugs. This class includes common drugs such as ibuprofen and naproxen, which can cause the body to hold on to salt and water. Of course, a patient with a sore back who takes them every day may be adding to the problem without knowing it.
Neurontin, or gabapentin, and Lyrica, or pregabalin, are often prescribed to Suboxone patients by other doctors for nerve pain, and both are well known for causing swelling of the feet and legs. So, when a Suboxone patient’s ankles swell, the first thing I do is read the whole medication list, not just the top line.
Sometimes the fix is not the Suboxone dose at all. It is the other drug, and a doctor who only knows about the Suboxone will adjust the wrong one.
Does putting your feet up or cutting back on salt help?
Yes, within limits, and they are the first things to try while you wait for the appointment. Gravity put the fluid there, and gravity can take some of it back.
An analogy that might help is a garden hose running uphill. Water climbs the hose only as fast as the pressure behind it pushes, and if you lay the hose flat, or tip it downhill, it drains on its own. The veins in your legs work against that same hill all day.
While this is not a perfect analogy, it explains the advice. Lie down with your feet above the level of your heart for a while in the evening, and the fluid drains back toward the middle of the body, where the kidneys can get rid of it. Walking helps for a similar reason, because the calf muscles pump blood upward with every step, which is why the swelling is often worst after a day of standing still or a long flight.
Salt makes the body hold water, so a heavy-salt diet makes any edema worse, and cutting back on salty food is a reasonable step that rarely hurts anyone. What I would not do is restrict water. Drug-related edema is not caused by drinking too much, and drinking less does not fix it, so leave any decision about fluids to a doctor who knows your heart and kidneys. None of this replaces the visit.
What about compression socks? Can they help with the swelling?
You may have heard of compression stockings or socks that squeeze the ankles while you wear them. These garments hold in the swelling and help the body get the fluid back into the veins, to go up and out of the legs. In many cases, compression socks will not be harmful and may be helpful.
Still, you must speak with your doctor about this first. A doctor will want to know that the swelling is not a clot, and that the circulation in your legs is good enough for a tight sock, and may choose to address the underlying problem before recommending long-term use.
So, a tight sock treats the symptom, while a dose adjustment treats the cause, and there is no point in wearing one every day for a problem that a conversation with your prescriber could fix. Ask about the dose first.
Are there alternative medications for opioid dependence that do not cause ankle swelling?
The alternative to Suboxone and the other buprenorphine medications is naltrexone, an opioid blocker. Naltrexone is not an opioid, and it does not commonly cause ankle swelling.
While naltrexone does not cause the swelling, switching to it is not a remedy for a swollen ankle. It is a completely different treatment decision. Naltrexone blocks the opioid receptor, and if it is taken while buprenorphine is still on the receptor, it throws the patient into sudden and severe withdrawal. So, the switch means stopping buprenorphine and waiting, opioid-free, for a week to two weeks before the first dose, a hard and risky stretch for anyone who is doing well.
In an earlier version of this article, I suggested that naltrexone in low doses might help with edema. That was a clinical impression, not evidence, and I have removed it.
For a patient who is stable on buprenorphine, a swollen ankle is a reason to adjust the buprenorphine, not to abandon it. And, the dose matters far more than the brand, so trading a film for a tablet rarely changes the swelling.
Patients ask me the same three questions about Suboxone swelling.
Is water retention from Suboxone dangerous?
Usually, no. Suboxone can cause water retention, and the prescribing information lists peripheral edema among the most frequently reported side effects since the medication came to market. In most patients it is mild and improves with a dose adjustment. It is dangerous when it is not from the Suboxone, which is why every case needs an examination, and why the emergency symptoms listed above mean emergency care.
Does Suboxone swelling go away?
Usually, yes, once the prescriber lowers the dose or removes another medication that was adding to it. Unfortunately, I cannot promise a timeline, and swelling that does not improve after a dose change needs another look for a different cause.
Does the Suboxone dose matter?
Yes. In my experience the swelling is more common at higher doses and often better at lower ones. That does not mean you should lower the dose yourself, because a dose that is too low brings back withdrawal and cravings. Work with your prescriber on the smallest dose that keeps you well.
Suboxone swelling is usually minor, and it is always evaluated.
You can rest assured that a bit of ankle swelling is most likely not going to be a big problem if it is due to Suboxone treatment, once a doctor has confirmed that Suboxone is the reason. Usually, the fix is a small adjustment.
If you are just getting started with Suboxone, do not let this symptom discourage you. The swelling can be improved by making changes to your therapy, and the therapy itself is what is keeping you well.
Physical dependence is not addiction. Some people on buprenorphine are treating a dependence that began with a prescription, others are treating an addiction, and a swollen ankle says nothing about which one you are. It is a side effect of a medication, and your doctor can manage it.
So, while Suboxone can make your legs and feet swell, the swelling can be improved without too much difficulty. Tell your doctor, show them the ankle, in person if you can, and let the two of you decide what to change.
Dr. Leeds treats opioid dependence with buprenorphine by telemedicine in Florida.
Dr. Leeds provides buprenorphine treatment with Suboxone and its film and tablet generics to new patients throughout Florida by telemedicine, with in-office visits available in Fort Lauderdale when a hands-on examination is needed. Induction is done at home with phone support, and when fentanyl is involved, a low-dose initiation is used. Care is one-on-one and patient directed, and side effects such as swelling are handled by adjusting the treatment together with the patient, never by leaving the patient to adjust it alone.
If you are on Suboxone and your ankles are swelling, or you are considering opioid dependence treatment, contact Dr. Leeds through the contact form.
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.
