How To Prep For Opioid Withdrawals When Beginning Suboxone Treatment — The First 10 Days

December 18, 2020

Transitioning from opioids to buprenorphine/naloxone (Suboxone) can be an intimidating process. Thinking about giving up opioids after being dependent on them can be daunting, as can the actual transition (also called “induction”). Some people have had the unpleasant experience of trying to take buprenorphine/naloxone (Suboxone) without going through opioid withdrawal first, which can make someone feel very ill, although it is generally not dangerous. 

Most people who are dependent on opioids have felt withdrawal symptoms at one time or another. Withdrawal from opioids can include obvious symptoms like nausea/vomiting/diarrhea, anxiety, and restlessness, as well as less obvious symptoms like dilated (large) pupils and gooseflesh.

It is true that you will have to go through some withdrawal symptoms to transition from opioids to buprenorphine/naloxone (Suboxone). Bicycle Health’s care team will be with you along the way to ensure a transition that is as safe and comfortable as possible. 

Why do I have to go through withdrawal symptoms?

Opioids act at the “opioid receptors,” which are proteins throughout the body where opioids carry out functions like pain relief and euphoria. Buprenorphine sticks in those receptors much more strongly than opioids and kicks opioids out of the receptors. When this happens, the patient can experience sudden and severe withdrawal symptoms called “precipitated withdrawal.” By going through moderate withdrawal prior to taking buprenorphine/naloxone (Suboxone), this “precipitated withdrawal” can be avoided.

Despite withdrawal symptoms, it is considered safe and effective for most patients to start buprenorphine/naloxone (Suboxone) at home in a comfortable and familiar environment, without the dangers of driving while in withdrawal or taking a new medication. In the COVID-19 era, self-management with expert support is even more critical to avoid potential exposure to the virus in healthcare settings. Your medical provider can assist you in deciding if this is the right pathway for you. 

Different opioid types require different lengths of time to achieve sufficient withdrawal to start buprenorphine/naloxone (Suboxone). The following examples are rough estimates of the hours it takes to withdrawal from various substance, which also varies from person to person: 

  • Short-acting opioids including heroin, oxycodone/Percocet, hydrocodone/Vicodin/Lortab, and kratom: approximately 12-16 hours
  • Long-acting opioids including Oxycontin, MSContin, Opana ER: approximately 20-24 hours
  • Methadone: approximately 48 hours
  • Fentanyl: approximately 72 hours but varies by method of use

How do I prepare for opioid withdrawal and Suboxone induction?

  • The best way to prepare for induction is to consult with your medical provider and have all your questions answered ahead of time. Bicycle Health providers will walk you through the process before you start your first medication.
  • Make sure that you have your medications (including buprenorphine/naloxone (Suboxone) and comfort medications) before you start the withdrawal process so that you do not have to go to the pharmacy once you start to feel ill. 
  • Prepare a comfortable environment at home with a bathroom nearby, as you may have unpleasant symptoms such as vomiting and/or diarrhea

How do I manage withdrawal symptoms? 

  • Your medical provider can select targeted medications that help with specific withdrawal symptoms such as diarrhea, nausea, anxiety, and muscle aches.
  • Stay in your comfortable, safe, and private environment with a bathroom nearby. You can use distraction techniques, meditation, or other comfort measures that work for you. 
  • Use Bicycle Health’s withdrawal tool to help measure severity and assess when you are ready to take buprenorphine/naloxone (Suboxone) by assigning a numerical score to each symptom. A similar tool can be found here.
  • Listen to your body. Keep in mind that if you are feeling so ill that you do not feel you can tolerate any further withdrawals, you are most likely ready to start a small amount of buprenorphine/naloxone (Suboxone). Check your symptoms against Bicycle Health’s withdrawal severity tool to be sure. 
  • If you feel something is wrong (such as so much vomiting that you become dehydrated), contact Bicycle Health during business hours or consider going to urgent care/the emergency room after hours. Home induction of buprenorphine/naloxone (Suboxone) is considered to be safe for most individuals, and it is rare that emergency help is needed. 
  • You can read more about managing withdrawal symptoms here.

The first 10 days with Bicycle Health

Bicycle Health is here to help you through this process from start to finish with these day-by-day steps:

Day 1

What you do with Bicycle Health

  • Meet with your medical provider for assessment by a “telemedicine” platform where the provider and patient can see each other via the internet. 
  • Receive written instructions on how to safely start buprenorphine/naloxone (Suboxone).
  • Receive a short prescription for buprenorphine/naloxone (Suboxone) and comfort medications if you meet the criteria for opioid use disorder (addiction to opioids) and Bicycle Health’s criteria. Bicycle Health providers usually provide about 12mg of buprenorphine/naloxone (Suboxone) the first day, followed by an increase to 16mg on day 2.

What you do at home

  • Stop your opioids and allow the withdrawal process to begin. 
  • Monitor your symptoms using Bicycle Health’s tool to measure withdrawal severity.
  • Take comfort medications as needed.
  • Start a small amount of buprenorphine/naloxone (Suboxone) when your withdrawal is severe enough when measured on the SOWS scale. 

Day 2-3 (or one day after your anticipated start)

What you do with Bicycle Health

  • Meet with your medical provider again to assess your status, make appropriate medication adjustments, and answer any questions. 
  • Receive instructions and prompts to complete urine drug screens at home. 

What you do at home

  • Continue your 12mg dose of buprenorphine/naloxone (Suboxone) or increase it to 16mg (based on provider’s guidance). 
  • Monitor your symptoms - especially cravings and withdrawals - to report back to your medical provider at each visit. 
  • Complete the first urine drug screen at home and show results via your cell phone camera. 

Day 7-10

What you do with Bicycle Health

  • Meet with your medical provider periodically to assess your status, make appropriate medication adjustments, and answer any questions. 

What you do at home

  • Monitor your symptoms - especially cravings and withdrawals - to report back to your medical provider at each visit. 

After Day 10

Once you feel comfortable on your dose, your medical provider will see you weekly until you are stable with appropriate drug screens. 

Opioid withdrawal tips and tricks

Here are some tips and tricks to help you get through withdrawal symptoms and the induction process:

  • If you have supportive friends and family who are aware of your condition, enlist them to check on you periodically.
  • Plan to take a day or two off to make the transition from opioids to buprenorphine/naloxone (Suboxone). If you work, you might pick a weekend to start. If you have young children, make sure you have help caring for them if at all possible. 
  • Do not intentionally start the withdrawal process prior to talking to your medical provider - it is difficult to communicate effectively when you are already feeling ill.
  • You do NOT need to cut down your opioid dose ahead of time. Cutting down opioid doses ahead of induction to buprenorphine/naloxone (Suboxone) rarely helps but does cause unnecessary discomfort. 
  • Know that buprenorphine/naloxone (Suboxone) stops withdrawal symptoms in almost all patients, even those with severe withdrawals or high-dose opioids. If you do not feel that this medication is relieving your symptoms, please contact Bicycle Health for assistance. 

To learn more about the success rates and safety of Bicycle Health’s telemedicine addiction treatment in comparison to other common treatment options, call us at (844) 943-2514 or schedule an appointment here.


About the Author

Dr. Julie Craig, MD

Dr. Julie Craig is board certified in family medicine (2010) and addiction medicine (2015). She attended medical school at Oregon Health & Science University, then completed the Northern New Mexico Family Medicine Residency Program in Santa Fe.

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