Precipitated Withdrawal

Precipitated withdrawal is the rapid and intense onset of opioid withdrawal symptoms triggered by certain medications, such as Suboxone — a combination of buprenorphine and naloxone — and naltrexone. Symptoms are often severe and may require hospitalization.
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Suboxone, Subutex and naltrexone are effective treatments that can help people overcome opioid addiction. Suboxone and Subutex are formulations of buprenorphine, a drug that activates opioid receptors and suppresses withdrawal symptoms. Naltrexone and naloxone do not activate opioid receptors. They work by blocking opioid receptors in the brain.

If these drugs are taken too early during the detox process, they can bring on sudden and severe withdrawal symptoms.

Precipitated withdrawal can cause excessive vomiting, profuse diarrhea, drenching sweats and other symptoms. These dire reactions sometimes require hospitalization.

Fortunately, there are ways to reduce the chances of experiencing precipitated withdrawal. That’s why it’s important to seek the assistance of an experienced treatment team with a keen understanding of the phenomenon.

What Causes Precipitated Withdrawal?

Precipitated withdrawal is an accelerated withdrawal that occurs when medication-assisted treatments are started without enough lag time between the last dose of heroin or prescription painkiller and the first dose of the medication used to treat opioid addiction.

Normally, opioid withdrawal happens gradually over the course of a few days or weeks as the body rids itself of the drugs and readjusts. But drugs such as buprenorphine and naltrexone can speed and worsen the process if they’re not used correctly.

Suboxone, a popular opioid replacement therapy, binds to the brain’s opioid receptors, but it doesn’t stimulate them as strongly. As a result, it doesn’t trigger the same sort of euphoric sensations as other opioids — but it will suppress withdrawal symptoms and stop cravings.

There is, however, an important caveat. The person must already be in the mild to moderate stages of opioid withdrawal when they start Suboxone. If they aren’t, the drug will knock any remaining opioids off the brain’s receptors and plunge the person into an immediate and agonizing withdrawal.

Naltrexone, another common opioid addiction treatment, can also cause precipitated withdrawal. Like buprenorphine, naltrexone relieves cravings and blocks the euphoric effects of opioids. It does not relieve opioid withdrawal symptoms, however, and will bring them on suddenly if a person is not completely opioid-free when they start the medication.

A person can also develop precipitated withdrawal when switching from buprenorphine to naltrexone. The drug naloxone — the other active ingredient in Suboxone, alongside buprenorphine — is used to reverse opioid overdose and can also cause a sudden opioid withdrawal. But the symptoms do not last as long as they do with naltrexone and buprenorphine.

How Long Does Precipitated Withdrawal Last?

Precipitated withdrawal develops rapidly. With Suboxone, symptoms develop within one to two hours of the first dose and usually resolve within a few hours but can last as upwards of one day.

Precipitated withdrawal from naltrexone may develop within minutes. It can to last up to 48 hours. Withdrawal symptoms associated with naloxone are short-lived, lasting only 30 minutes to an hour, on average.

Symptoms of Precipitated Withdrawal

Precipitated withdrawal can make a person violently ill. The symptoms of precipitated withdrawal are more severe than spontaneous opioid withdrawal.

Signs and symptoms of precipitated withdrawal include:

  • Excessive and projectile vomiting
  • Abdominal cramps
  • Profuse diarrhea
  • Severe muscle cramps and body aches
  • Seizures
  • Altered levels of consciousness
  • Fever
  • Low blood pressure
  • Elevated heart rate
  • Severe headache
  • Flushing
  • Sweating and chills
  • Dilated pupils
  • Severe anxiety and agitation

Several factors can determine the severity of these symptoms, including the duration of misuse, the opioid used, and a person’s physical and biological attributes.

How to Stop Precipitated Withdrawal

People usually don’t die from precipitated withdrawal, but they may need hospitalization. Some patients require intensive care.

If you develop precipitated withdrawal after your first dose of Suboxone, your doctor may administer additional doses of the drug. This may be enough to suppress withdrawal symptoms.

You may also need supportive care. Typical treatments include intravenous fluids, sedatives, anti-nausea medications and other medications. Extremely agitated patients may require heavy sedation or general anesthesia.

Avoiding Precipitated Withdrawal

Timing is the key to avoiding precipitated withdrawal. Individuals should observe a specific opioid-free interval before starting Suboxone or naltrexone.

You should wait at least 12 to 24 hours after your last use of a short-acting opioid, such as oxycodone or heroin, before starting Suboxone. If you’re using a long-acting opioid, such as Oxycontin or methadone, you should wait at least one to two days.

Other risk factors for a developing precipitated withdrawal with buprenorphine include:

  • A high first dose of buprenorphine (greater than 4-8 mg)
  • Heavier use of opioids or higher level of physical dependence
  • Starting buprenorphine within 2 hours of the last dose of opioids

Naltrexone requires a longer drug-free window to reduce the risk of precipitated withdrawal. A person should be opioid-free for at least seven to 10 days before starting the drug. When switching from methadone to naltrexone, a person must fully detox from methadone first. This can take up to two weeks.

To lower your risk of precipitated withdrawal, take your opioid replacement therapy only as directed. Be honest with your treatment team about the last time you used opioids. If you develop any of the signs or symptoms mentioned above, seek immediate medical attention and contact your doctor.

Medical Disclaimer: aims to improve the quality of life for people struggling with a substance use or mental health disorder with fact-based content about the nature of behavioral health conditions, treatment options and their related outcomes. We publish material that is researched, cited, edited and reviewed by licensed medical professionals. The information we provide is not intended to be a substitute for professional medical advice, diagnosis or treatment. It should not be used in place of the advice of your physician or other qualified healthcare provider.

Amy Keller, RN, BSN
Content Writer,
As a former journalist and a registered nurse, Amy draws on her clinical experience, compassion and storytelling skills to provide insight into the disease of addiction and treatment options. Amy has completed the American Psychiatric Nurses Association’s course on Effective Treatments for Opioid Use Disorder and continuing education on Screening, Brief Intervention and Referral to Treatment (SBIRT). Amy is an advocate for patient- and family-centered care. She previously participated in Moffitt Cancer Center’s patient and family advisory program and was a speaker at the Institute of Patient-and Family-Centered Care’s 2015 national conference.
Kim Borwick, MA

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