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What Is Precipitated Withdrawal & How Long Does It Last?

April 18, 2022

Precipitated withdrawal can last from several hours to several 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.

Certain medications like buprenorphine, naloxone, and naltrexone can all induce precipitated withdrawal if the individual has not completely removed opioids from their body.

he severity of withdrawal symptoms and whether treatment is necessary depends on the drug that has triggered precipitated withdrawal, your history of opioid use and your overall health.

How Long Does Precipitated Withdrawal Last?

Precipitated withdrawal is a sudden, rapid onset of withdrawal symptoms that can last for hours or even days, depending on the severity of the individual’s opioid use disorder (OUD). This condition is reportedly more intense and painful than acute withdrawal from opioids, which is also a very uncomfortable condition.[1]

It is likely that the suddenness and severity of the experience is related to the causes of precipitated withdrawal. Rather than easing opioids out of the body by not taking another dose, which causes acute withdrawal, precipitated withdrawal involves one medication, often an opioid antagonist, forcibly removing opioids from receptors in the brain.

What Medications Can Trigger Precipitated Withdrawal?

Precipitated withdrawal is associated with opioid use disorder and a class of medications called opioid antagonists. There are three common drugs that might trigger precipitated withdrawal.

Naloxone

This medication was designed to rapidly, 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, but the half-life of this medication is far less than that of many full opioid agonists so the effect is temporary.[2]

Naloxone has proven to be a lifesaving medicine. It is becoming widely available for emergency use at pharmacies, doctors’ offices, and other locations including at-home.

Naloxone is one of two ingredients in Suboxone, a medication prescribed to help people overcoming opioid dependence. Suboxone helps people to become physically stable by stopping withdrawal symptoms.

If a person attempts to misuse or tamper with Suboxone, naloxone becomes the active ingredient. This means it will remove any opioids in the brain from those receptors, which can very suddenly trigger withdrawal symptoms.

Naltrexone / Vivitrol

This medication is also an opioid antagonist, but it lasts far longer than naloxone and has very different prescription uses.

Naltrexone is not prescribed to stop overdoses. Instead, it is taken regularly to stop 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, and this 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.[5]

Since buprenorphine does not trigger strong intoxication, especially in people who have an opioid tolerance, this sudden replacement can cause withdrawal symptoms.

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. Even if acute withdrawal begins after a day or so, this will be managed by buprenorphine treatment.

Precipitated withdrawal is most common in people taking buprenorphine. This may happen if they begin opioid addiction treatment before other opioids have left their body, or if they attempt to overcome their opioid use disorder without medical supervision.

Precipitated Withdrawal Symptoms & Their Duration

Symptoms associated with precipitated withdrawal are like those of 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 buprenorphine/naloxone treatment, precipitated withdrawal can be managed safely. However, its onset is very disruptive.

Why Does Precipitated Withdrawal Occur?

Withdrawal symptoms are a common experience when quitting opioids, even if these have been prescribed as necessary medical treatment.

People who enter treatment for opioid user disorder must stop taking opioids, which means that they are likely to experience the early stages of acute withdrawal as the opioids naturally metabolize out of their body. Typically, this lasts one to two days.

With medical oversight, buprenorphine treatment will start once the overseeing physician is sure that there are no more opioids in the individual’s body.

Precipitated withdrawal occurs if opioids are suddenly, forcibly removed from the brain’s receptors rather than being allowed to metabolize out naturally. Sometimes, buprenorphine can actually be used to treat this condition, but it may require urgent medical care to manage.[7]

How Is Precipitated Withdrawal Best Treated?

Attempting to treat precipitated withdrawal at home is not recommended unless you have direct medical supervision.

Treatment protocols, as well as the time that it takes for your body to recover, depends on the drug that has triggered precipitated withdrawal, your history of opioid use and your overall health. The timeline can range from several hours to a few days.

Depending on these factors, precipitated withdrawal may be considered a medical emergency. It may require hospitalization. This is more often the case with emergency administration of Narcan (naloxone) to treat an opioid overdose.

When caused by Suboxone, precipitated withdrawal is often mild and shorter-lived.

Your doctor may recommend medications for home treatment, including:

  • Nonsteroidal anti-inflammatory drugs (NSAIDs)like ibuprofen or acetaminophen.[8]
  • Antiemetics to reduce nausea and vomiting.
  • Clonidine, which is also prescribed to manage blood pressure.
  • Lofexidine, which is used to manage sickness from opioid withdrawal.[9]

It is important to work closely with your overseeing physician when you begin treatment for opioid use disorder. Medical professionals will monitor you closely after you stop taking opioids. As you begin to experience acute withdrawal symptoms as your body finishes metabolizing out the last dose of opioids, you will begin buprenorphine or Suboxone treatment. This is an individual process, as starting with too high a dose too early can trigger precipitated withdrawal.

Fortunately, the likelihood of precipitated withdrawal associated with buprenorphine treatment is low, and is extremely unlikely if you follow your doctor’s guidance. [10]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.

Brian Clear, MD, FASAM — Medical Director

Brian Clear, MD, FASAM, is board certified in Family Medicine and Addiction Medicine, and he joined Bicycle Health in early 2020 as Medical Director and President of the Medical Provider Group.

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Citations

1. Quattlebaum THN, Kiyokawa M, Murata KA. A case of buprenorphine-precipitated withdrawal managed with high-dose buprenorphine[published online ahead of print, 2021 Jun 26]. Fam Pract. 2021; cmab073. https://pubmed.ncbi.nlm.nih.gov/34173647/.

2. Naloxone DrugFacts. National Institute on Drug Abuse (NIDA). https://www.drugabuse.gov/publications/drugfacts/naloxone. June 2021. Accessed December 2021.

3. Naltrexone. MedlinePlus. https://medlineplus.gov/druginfo/meds/a685041.html.December 2021. Accessed December 2021.

4. Kunzler, Nathan M.; Wightman, Rachel S.; Nelson, Lewis S. Opioid Withdrawal Precipitated by Long-Acting Antagonists. Clinical Reviews in Emergency Medicine. February 2020; Volume 58 (Issue 2), p. 245-253.DOI: https://doi.org/10.1016/j.jemermed.2019.12.015.

5. Fact Sheet: Buprenorphine. Blue Cross Blue Shield of Massachusetts. https://www.umassmed.edu/globalassets/center-for-integrated-primary-care/amber/final-fact-sheet-on-buprenorphine-final.pdf. Accessed December 2021.

6. Opiate and Opioid Withdrawal. MedlinePlus. https://medlineplus.gov/ency/article/000949.htm. November 2021. Accessed December 2021.

7. Oakley, Bridget; Wilson, Hester; Hayes,Victoria; Lintzeris, Nicholas. Managing Opioid Withdrawal Precipitated by Buprenorphine with Buprenorphine. Drug and Alcohol Review. May 2021;Volume 40 (Issue 4), p. 567-571. DOI: https://doi.org/10.1111/dar.13228.

8. Frequently Asked Questions about ED-Initiated Buprenorphine. National Institute on Drug Abuse (NIDA). https://www.drugabuse.gov/nidamed-medical-health-professionals/discipline-specific-resources/emergency-physicians-first-responders/initiating-buprenorphine-treatment-in-emergency-department/frequently-asked-questions-about-ed-initiated-buprenorphine. September 2019. Accessed December 2021.

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