Precipitated withdrawal is withdrawal symptoms that are “precipitated” or brought on by taking an opioid antagonist (Naltrexone) or partial agonist (Buprenorphine) too soon after taking a full opioid agonist (heroine, oxycodone, morphine, etc.). Precipitated withdrawal can last for hours or even days, depending on the severity of the individual’s opioid use disorder (OUD). [1]
In order to prevent precipitated withdrawal when taking a new medication like Suboxone or Naltrexone, talk with your doctor and let them know the last time you used any opioids prior to starting these medications.
What Is Precipitated Withdrawal?
Precipitated withdrawal is withdrawal symptoms that are “precipitated” or brought on by taking an opioid antagonist (Naltrexone) or partial agonist (Buprenorphine) too soon after taking a full opioid agonist (heroine, oxycodone, morphine, etc.).
The symptoms themselves are the same as the symptoms of natural withdrawal from opioids, but might come on more quickly.
How Long Does Precipitated Withdrawal Last?
Some people experience precipitated withdrawal for just a few hours. Others may have symptoms for days. The specific timeline will vary according to the level of physical dependence, the medications and dosages that may have induced precipitated withdrawal, and the treatment support given.
What Medications Can Trigger Precipitated Withdrawal?
Precipitated withdrawal is associated with opioid use disorder and a class of medications called opioid antagonists. Three common drugs might trigger precipitated withdrawal.
Naloxone
This medication was designed to rapidly and temporarily stop opioid overdoses, so the individual suffering the overdose has time to receive emergency medical treatment. Naloxone binds to opioid receptors and forces opioids off the receptors. The half-life of this medication is far less than that of many full opioid agonists, so the effect is temporary.[2]
Naltrexone (Vivitrol)
This medication is also an opioid antagonist but lasts far longer than naloxone and has very different prescription uses.
Naltrexone is not prescribed to stop overdoses. Instead, it is taken regularly to prevent intoxication or euphoria in the event of a relapse.[3]
Naltrexone binds to the opioid receptors in the brain for either hours or days, depending on the dose and formula. If the individual relapses and takes opioids, they will not experience positive sensations or sedation while naltrexone is active in the body.
To start naltrexone treatment, a person must completely stop taking any opioid, including buprenorphine or methadone. If opioids are still in the bloodstream, naltrexone will stop all their effects on the brain, which can induce precipitated withdrawal.[4]
Buprenorphine
This medication is not an opioid antagonist but a partial opioid agonist. However, it is a “stronger magnet” than many other opioids, including heroin, oxycodone, or hydrocodone. This means buprenorphine binds more readily to receptors in the brain than most full opioid agonists, thus replacing them quickly and causing a precipitated withdrawal. [5]
Doctors who prescribe buprenorphine treatment for opioid use disorder note the importance of ensuring an individual has stopped taking opioid drugs like heroin long enough before beginning treatment to avoid precipitated withdrawal.
Precipitated Withdrawal Symptoms & Their Duration
Symptoms associated with precipitated withdrawal are like acute opioid withdrawal, but they typically occur faster and feel more intense.
Symptoms include the following:
- Agitation, restlessness, and anxiety
- Muscle aches
- Increased watering of the eyes
- Insomnia
- Sweating
- Yawning
- Runny nose
- Abdominal cramps
- Diarrhea and nausea
- Dilated pupils
- Goosebumps[6]
With treatment, including continuing Suboxone treatment, precipitated withdrawal can be managed safely. However, its onset is very disruptive.
Why Does Precipitated Withdrawal Happen?
Medications like buprenorphine and naloxone bind to opioid receptors in the brain more strongly than full opioid agonists. This is a little counterintuitive: The stronger the opioid, the weaker the binding to opioid receptors. Even though Suboxone and Naltrexone/Naloxone are actually weaker opioids than full agonists, they bind more strongly to opioid receptors. They bind preferentially over the opioid, which can kick opioids quickly off the receptors and precipitate withdrawal.
How Is Precipitated Withdrawal Best Treated/Prevented?
The best treatment is simply prevention: Making sure not to take a partial opioid agonist like Buprenorphine or an antagonist like Naloxone or Naltrexone too soon after taking a full opioid agonist.
If you do experience withdrawal, either natural or precipitated, there are some adjunctive medications that can help to ease symptoms, including:
- Nonsteroidal anti-inflammatory drugs (NSAIDs) like ibuprofen or acetaminophen[7]
- Antiemetics to reduce nausea and vomiting
- Clonidine to manage blood pressure
- Lofexidine to manage sickness from opioid withdrawal[8]
How Common Is Precipitated Withdrawal?
Fortunately, with buprenorphine treatment, the likelihood of precipitated withdrawal is low, particularly if you follow your doctor’s guidance.[9] When precipitated withdrawal from buprenorphine does occur, it is often mild and brief.
If you follow your doctor’s directions closely, the process of beginning Suboxone therapy is quite manageable, and precipitated withdrawal is of little concern. Suboxone is a very safe and effective treatment that has helped millions of people reclaim their lives from opioid use disorder.
Precipitated Withdrawal FAQs
How long does precipitated withdrawal last?
Everyone is a little different, but most people move through precipitated withdrawal in just a few hours.
Why does buprenorphine cause precipitated withdrawal?
Buprenorphine is a partial opioid agonist, capable of latching to receptors used by heroin and prescription painkillers. Take a dose, and it can displace stronger drugs from their attachments and trigger withdrawal. This is called “precipitated” withdrawal when withdrawal is induced by taking a drug.
How long do I have to wait to take Suboxone?
Your wait times can vary, depending on what drugs you took, how long you've used drugs, and how quickly your body processes drugs. Your treatment team can tell you how long you should wait to take Suboxone. The recommended period between stopping full opioids and starting a partial opioid agonist or antagonist is usually somewhere between 12 to 48 hours.
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