Precipitated withdrawal is when Suboxone makes you dope sick.

If you take a Suboxone and you suddenly get withdrawal symptoms, that is what we mean by precipitated withdrawal. While precipitated withdrawal from Suboxone is typically not dangerous, it is very unpleasant. In fact, the main reason that doctors don’t want their patients to suffer from precipitated withdrawal is that we do not want our patients to think that Suboxone does not work. If patients who are addicted to opiates and opioids think that Suboxone just makes them feel sick, they will likely not want to give it a second chance. We do not want our patients to have a bad experience with Suboxone because it is one of the best treatments for opioid addiction.

Why does precipitated withdrawal happen after taking Suboxone?

The Suboxone ingredient that causes the problem is buprenorphine. Many people blame the other ingredient in Suboxone, which is naloxone. The fact is that naloxone contained in Suboxone does not cause precipitated withdrawal when the Suboxone is taken as directed. But, if buprenorphine is an opioid itself, and it is the drug that is supposed to make withdrawal symptoms go away, how can it cause withdrawal?

Understanding how buprenorphine causes precipitated withdrawal.

Buprenorphine is a very unique opioid. It is known as a partial opioid agonist and an opioid antagonist at the same time. Understanding what this means is easier than it sounds. Buprenorphine binds strongly to opioid receptors. In fact, it is believed that the molecule binds to the mu receptor permanently, making it impossible for any opioids to bind to that blocked receptor. While the bupe molecule is attached to the receptor, it partially activates it. Therefore, it gives the effects of an opioid, but more mildly than most opioids. The molecules of other kinds of opioids will bind to a receptor, fully activate it, and then let go. The same molecule may bounce on and off of many receptors, repeatedly fully activating them many times before the molecule finally leaves the body. When buprenorphine is present on an opioid receptor, no opioid may attach to activate it. Buprenorphine blocks and partially activates the receptor.

A model to better understand buprenorphine versus other opioids.

I sometimes explain the above process to patients using an elevator button analogy. While not perfect, it does help to make some sense of what seems like a complex process. Imagine that an opioid, such as heroin or oxycodone, is present in a person’s system. Think of these molecules like misbehaving children in an elevator. Imagine the kids poking all of the elevator buttons over and over. The buttons represent opioid receptors. The children can’t help but poke buttons over and over until every floor is selected. Now, imagine a responsible adult enters the elevator. The adult stands in front of the buttons, blocking them from the children. Now, the adult carefully presses a button. This adult represents the drug, buprenorphine.

The benefits of buprenorphine over other opioids.

Because buprenorphine activates the opioid receptor, it can provide benefits such as pain relief as well as helping with anxiety and depression. It also prevents prolonged opioid withdrawal after an opioid addict has quit heroin or prescription opioids. By blocking the receptor, the patient is less likely to develop tolerance, where the medicine stops working and more is required to get the same effect. Tolerance is common with other opioids. Also, blocking the receptor is important in preventing opioid cravings. While buprenorphine is very effective in treating opioid addiction, it is useful in treating chronic pain as well. In fact, many patients with chronic pain who are unable to get other opioids prescribed anymore find that buprenorphine provides adequate pain relief.

Back to precipitated withdrawal.

So if buprenorphine is an opioid and so superior to other opioids, why does it make patients sick sometimes? Precipitated withdrawal is simply what happens when Suboxone, or another med containing buprenorphine, is taken too soon after another opioid. When you stop taking an opioid and you start to get a little sick with withdrawal symptoms, you may not be aware of it, but you still have opioid in your system. Now, if you take Suboxone too soon, the buprenorphine quickly blocks many receptors. As a result, your receptor stimulation drops quickly. While buprenorphine does activate the receptor, it does it more mildly than the other opioid in your system. It is like slowing your car from 100 miles per hour down to 30 miles per hour instantly. While it is not like running into a wall, slowing down that fast can almost feel like you hit a wall. Yet, 30 miles per hour is still faster than a person can run. It is double the speed limit in a school zone. It is fast enough to cause damage to your car and significant injury in an accident. But still, going from 100 to 30 is a jolt and can make you feel very shaken up.

Precipitated withdrawal from Suboxone is not as bad as naloxone-precipitated withdrawal.

Naloxone is the ingredient in Narcan, an emergency rescue drug to give to people who are overdosing on an opioid or opiate, such as heroin or fentanyl. Narcan is a powerful opioid receptor blocker that can reverse respiratory depression that occurs in an overdose. Unlike buprenorphine however, narcan does not at all stimulate the receptor. Because of this, Narcan, or naloxone, is not an opioid. It is just a blocker. So, taking Narcan while on opioids is more like going from 100 miles per hour down to 0 miles per hour almost instantly. It is basically just like hitting a wall. People who are given Narcan by paramedics after an overdose occurs often wake up in extreme distress. To say that they are uncomfortable is an understatement. The precipitated withdrawal caused by Narcan is worse than the withdrawal caused by Suboxone, or buprenorphine. It is important to understand that naloxone is very short-acting. If given to reverse an overdose, it may have to be given multiple times.

How can I avoid precipitated withdrawal from Suboxone?

When taking prescribed buprenorphine, it is important to follow directions. First of all, sublingual Suboxone film or buprenorphine tablets must always be allowed to fully dissolve under the tongue. And, most importantly, the first dose of buprenorphine should not be taken until you are fully ready. This means being in a moderate withdrawal state. A good way to know that you are ready is to use the Clinical Opiate Withdrawal Scale (COWS). This scale is available as a single worksheet that allows you to score your withdrawal symptoms. Your doctor will discuss this with you and help you to determine if you are ready to take your first dose of buprenorphine. While most people will be ready at 18-24 hours after taking the last short-acting opiate or opioid, in some cases, it can take longer. When you take your first dose of Suboxone or Subutex, your doctor may recommend a very small dose. This way, if you do experience precipitated withdrawal, it will not be as bad as if you had taken a larger dose.

Do not be discouraged.

Please, do not let precipitated withdrawal discourage you from trying Suboxone again. While it is unpleasant, it is not the end of the world. You can wait it out and try again. You will be glad that you stuck with it. Suboxone works really well when you give it a chance. Some patients will have very easy transitions in starting buprenorphine. Others will have a more difficult first week or so. There are medications that can help with withdrawal symptoms. Clonidine or Lucemyra are medications that can help to make it more tolerable. In some cases, your doctor may prescribe a short-term benzodiazepine or possibly gabapentin. If you do have precipitated withdrawal, you will get past it. As long as you do not go back to using opiates or opioids, you will get through it and stabilize on your medication-assisted treatment.

Do not fear precipitated withdrawal.

Please do not assume that you will go through precipitated withdrawal at all when you start Suboxone. Most often, it is avoided by following the guidelines of your doctor’s treatment plan. We wish you success in your recovery from opioid addiction!

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