Precipitated withdrawal refers to withdrawal that has been brought about by medication, rather than abstinence from a substance. It can be expected when naloxone is used to reverse an opioid overdose. As the opioid epidemic continues into its second decade, naloxone has become more and more common. However, a dose of naloxone in the form of a nasal spray, (the most common form) is high enough to cause the sudden, frightening, and painful reaction called precipitated withdrawal.
Why Does Precipitated Withdrawal Happen?
When using naloxone to reverse an overdose, precipitated withdrawal is expected. But, it can also happen unintentionally when certain medications are used to treat opioid use disorder (OUD). These medications include:
- Naltrexone (Vivitrol)
- Buprenorphine/naloxone (Suboxone, Zubsolv, Bunavail)
- Buprenorphine (Subutex, once-monthly Sublocade)
Precipitated withdrawal occurs when medication-assisted treatments are started without allowing for enough time between the last dose of prescription painkiller or heroin and the first dose of the medication.
Symptoms of Precipitated Withdrawal
A variety of uncomfortable symptoms can result from precipitated withdrawal. In general, it feels like the opposite of an opioid high. It brings sudden, intense pain and anxiety, rather than reduced pain and a feeling of euphoria. Other symptoms include:
- Nausea
- Excessive and projectile vomiting
- Stomach cramps
- Diarrhea
- Sweating and chills
- Chills
- Runny nose
- Severe headaches
- Seizures
- Fever
- Low blood pressure
- Rapid heart rate
- Anxiety and agitation
What’s the difference between precipitated and spontaneous withdrawal?
Spontaneous withdrawal occurs when you suddenly stop using a substance and tends to be a gradual process while precipitated withdrawal occurs quickly. This makes it an extremely painful and disorienting experience. It’s comparable to slowly maneuvering your car to a stop versus suddenly slamming on the brakes. In both cases, the car comes to a stop but they are strikingly different experiences.
Why Does it Happen?
You have opioid receptors all over your body but they are mainly in the brain and spinal cord.
Opioid receptors are the body’s internal system for regulating reward, pain, and addictive behaviors. It is made up of substances naturally produced in the body (endogenous opioids) and their receptors. These natural opioids fit the receptors like keys into locks.
Opioid Agonist
An opioid agonist, such as morphine, fentanyl, and heroin, is like another key to those locks. When it slides into the receptor, it “unlocks,” or activates the receptor causing a surge of signals that produce the effects related to opioids. These include pain relief, warmth, and euphoria.
On the other hand, opioid antagonists, such as naloxone and naltrexone, work in the opposite direction. They slide into the lock but don’t open it. This makes it unusable by opioid agonists for several minutes or even hours. For people who are dependent on opioids, the sudden loss of signals from the opioid receptors causes the symptoms of precipitated withdrawal. Opioid antagonists are important medications but it’s necessary to take them at the right time and in the right way to avoid precipitated withdrawal.
Partial Opioid Agonist: Buprenorphine
Despite not being an opioid antagonist, buprenorphine can also cause precipitated withdrawal. That’s because it is in a third category known as partial opioid agonists. Partial agonists sit on the receptor and occupy it, preventing it from being activated by anything else. However, they activate the receptor but only partially. It’s like putting a key in a lock and only turning it halfway. For a person dependent on opioids, the partial decrease in signaling from the receptors can still be enough to result in a precipitated withdrawal if not properly timed.
How Can You Avoid Precipitated Withdrawal?
The key to avoiding precipitated withdrawal is timing. You need to have a specific opioid-free period of time before starting Suboxone. Wait at least 12 to 24 hours after your last use of a short-acting opioid like oxycodone or heroin. If you’ve been using a long-acting opioid like Oxycontin or methadone, you need to wait at least 1 to 2 days.
To reduce the risk of precipitated withdrawal, take opioid replacement only as directed. And be honest with your physician or treatment team about the last time you used opioids.
How is Precipitated Withdrawal Treated?
Usually, people don’t die from precipitated withdrawal, but hospitalization may be necessary. Some people need intensive care. But you will need medical intervention, to say the least.
The simplest, most direct way to stop precipitated withdrawal is to take an opioid. This is a sticky situation if you’re trying to stop taking opioids. If you take an opioid to stop the precipitated withdrawal, you’ll need to wait until it leaves your system before you can continue treatment again with an opioid antagonist (naltrexone), or a partial agonist (buprenorphine).
Interestingly, you can ask a medical professional for a dose of buprenorphine to relieve your symptoms. That means that buprenorphine can cause a precipitated withdrawal and can also be used to treat it. If you’re dependent on opioids, switching from a full agonist like heroin to a partial agonist like buprenorphine can be enough to produce a precipitated withdrawal. Nevertheless, if you’re already experiencing precipitated withdrawal, buprenorphine can give you some relief.
Because buprenorphine is a partial agonist, it can’t duplicate the effects of a full agonist like heroin. Still, its partial activation of the opioid receptors is enough to ease the symptoms without risking an overdose. The problem is that many professionals hesitate to prescribe buprenorphine because of the stigma around opioid use disorder. In addition, physicians need to have completed an “x-waiver” to be able to prescribe it.
How Long Does Precipitated Withdrawal Last?
Without some type of mediation, the symptoms of precipitated withdrawal can range from several hours to several days. The timeline depends on several influences including your:
- Metabolism
- Opioid use history
- General health
Precipitated withdrawal develops rapidly. With Suboxone, the symptoms develop within one or two hours of the first dose. They usually subside within a few hours but can last the whole day. Precipitated withdrawal from naltrexone may develop within minutes and may last up to 48 hours. However, withdrawal symptoms linked with naloxone typically last 30 minutes to an hour.
What is Buprenorphine Treatment Like?
Day 1:
You can expect the first day of treatment to take about two hours. It’s essential for you to be in withdrawal before taking your first dose of buprenorphine. The first feelings you’ll have on the first day of treatment will be the first three symptoms of withdrawal that are specific to you. You may experience:
- Sweats
- Restlessness
- Anxiety
- Agitation
- Chills
- Stomach cramps
This is actually a good thing. It signals that relief is not too far off.
About twenty to thirty minutes after your first dose, you’ll start to feel those symptoms subside. In about an hour, the second dose should have you feeling relatively comfortable. Don’t be fooled into thinking you’re cured because you feel normal every day and night. It’s due to the medication so don’t be in a rush to get off the medication. Opioid addiction is a brain disease and is manageable because you can make the symptoms go away with buprenorphine. The disease itself doesn’t go away that fast.
Day 2:
You should have increased confidence in the ability of buprenorphine to make you feel better and be actively working to avoid any triggers to use.
Day 3-7:
Actively work to avoid triggers. You may actually feel like you did before using drugs.
Week 2:
This could be considered the “honeymoon” stage. You feel like you’re back in control and have a feeling of hopefulness. Still, you need to remain strict in your counseling and medication routine. This is also often the week that some people test the blocking effect of buprenorphine. They use drugs to see if it really blocks the effects, or just reduce them. The results are the same whether you try it out or learn from others. Buprenorphine blocks other opioids and you not only relapsed, but didn’t get high, and wasted money on drugs.
Week 3:
If you’re not in residential treatment, this is the time when your old drug-using companions will come around to see if you are ready to return to your former lifestyle. It’s important to remain strong now because it won’t be easy.
Week 4:
It may have been difficult for you to find employment or solve a relationship problem in the past. And it may be hard to stay optimistic not that a month has passed. Continue to work with your counselor to set small goals and accomplish them.
Months 2 and 3:
You should be comfortable taking your medication and like most people, just feel normal. Face your problems caused by drug use and you’ll find out what it’s like to be strong and successful. Continue your medication and counseling routines.
Why does Buprenorphine (Suboxone/Sublocade) Work?
It works because buprenorphine is much stronger at the receptor sites in the brain than any other opiates such as heroin, methadone, or painkillers. Because of that, some buprenorphine will be used to throw the other opiates off the sites resulting in a violent and rapid withdrawal. Then there might not be enough buprenorphine left to re-occupy the receptor sites. (precipitated withdrawal).
With buprenorphine, the effects of euphoria and respiratory depression are produced at lower doses and are weaker than with heroin and other full opioid agonists. Buprenorphine has pharmacological properties that help:
- Reduce the effects of physical dependency on opioids such as cravings and withdrawal symptoms
- Increase safety in case of overdose
- Reduce the likelihood of misuse
If you are already in mild withdrawal, a number of the receptor sites are already empty so most of the buprenorphine can be used for occupying them with little waste. However, don’t be fooled, you must be in mild to moderate withdrawal before taking buprenorphine for the first time.
Why You Need Medical Supervision When Using Buprenorphine
Common side effects of buprenorphine include:
- Headache, nausea, constipation, vomiting
- Dizziness
- Fatigue and drowsiness
- Sweating
- Dry mouth
- Tooth decay
- Sleep problems
- Muscle aches and cramps
- Fever
- Blurred vision
- Tremors
- Palpitations
- Attention disturbances
Serious side effects include:
- Respiratory distress
- Overdose
- Dependence
- Withdrawal
- Itching, pain, swelling, and nerve damage from an implant
- Pain at injection site from injection
- Neonatal abstinence syndrome in newborns
When taking buprenorphine:
- Don’t take other medications without talking to a doctor.
- Don’t use illegal drugs, sedatives, alcohol, or anything else that slows breathing. Mixing these substances can lead to overdose or death.
- Make sure to have a doctor monitor liver-related health problems you might have.
- Make sure your physician knows if you are pregnant or plan to become pregnant.
- Don’t share buprenorphine with anyone, even if they have similar symptoms.
Finding Treatment for Opioid Use Disorder
If you or someone you care about is struggling with a substance use disorder, there is an effective continuum of care at Jaywalker in Colorado. We are an immersive 12-step program for men that includes:
- Individual and group therapy
- Education
- Daily 12-step meetings
- Outdoor experiential therapy
Before joining Jaywalker, you will be in The Landing program to help you become oriented to the program, staff, and expectations. Our Solutions program helps you learn to live a sober lifestyle in a safe environment. You may even be able to go back to work or school on a part-time basis.
Jaywalker can also provide an outpatient program (OP) and a sober-living residence to continue your treatment which is an effective way to help prevent relapse.
Nevertheless, The Lodge is the heart of the treatment at Jaywalker. This is where you learn through mental health therapy how to live a drug and alcohol-free life.
You will enjoy physical challenges in the mountains and the company of a sober community to see things from a different perspective. Why wait? Contact us today
References:
https://www.ncbi.nlm.nih.gov/books/NBK54664
