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How Long Do I Have to Be in Withdrawal Before Starting Suboxone?

Suboxone is a Medication for Addiction Treatment (MAT). It is important to take it as prescribed, which includes beginning treatment at a specific time after you have ceased taking other opioid drugs. When you enter a drug rehabilitation program, you will work with a physician who will oversee the process of quitting an opioid like heroin, Vicodin, or OxyContin and beginning MAT with Suboxone.

Before you begin taking Suboxone, your body must fully metabolize out the last dose of other opioids. This will lead to withdrawal symptoms temporarily, before taking your first dose of Suboxone. When you start taking Suboxone and how much you take daily depends on which opioids you were using prior, how long you used them, and at what doses.

when you can start taking suboxone

Starting Suboxone

Before you begin Suboxone, you must ensure that all other opioids are out of the body. This means that you may experience withdrawal symptoms. In fact, having mild withdrawal symptoms is a good sign that there are no further opioids in your body and it is therefore the perfect time to start Suboxone.

Your physician might measure the severity of your withdrawal symptoms using a scale like the Clinical Opiate Withdrawal Scale (COWS).[1] To be considered in withdrawal, you will probably experience:

  • Twitching, tremors, or shaking
  • Enlarged pupils
  • Chills, shaking, or sweating
  • Heavy yawning
  • Joint, muscle, and bone aches
  • Runny nose or tears in your eyes
  • Goosebumps
  • Cramps, nausea, vomiting, or diarrhea
  • Feeling anxious or irritable
  • Insomnia

A COWS score of 11 to 12, which is generally mild to moderate opioid withdrawal symptoms, indicates that you can begin taking Suboxone.[2] Other clinicians might be less systematic and simply ask you to wait 12-14 hours after your last dose of an opioid prior to starting Suboxone.

If you begin Suboxone treatment at home, you should wait one hour after the onset of withdrawal symptoms and then take your first dose of Suboxone. You should feel relief within 30 minutes.

If you do not experience significant relief from withdrawal symptoms, you may need a larger dose. Your physician can guide you through the process of increasing your dose.

How Many Hours or Days Should You Wait Before Beginning Suboxone?

When you begin opioid addiction treatment with Suboxone, your physician will guide you on exactly when to start taking this medication. This is based on several individual factors.

In general, patients are counseled to wait a certain number of hours after taking their last opioid before starting their buprenorphine/naloxone (Suboxone) induction:[3]

  • Short-acting opioids: 6–12 hours after the last dose of opioids like heroin, Vicodin, Percocet, or Dilaudid 
  • Intermediate-acting opioids: 12–24 hours after the last dose of sustained-release OxyContin, morphine, or MS Contin
  • Long-acting opioids: 24–72 hours (1–3 days) after the last dose for medications like methadone

Once you begin Suboxone treatment, you will likely follow these general steps:

  • Take your first dose of Suboxone on day one 
  • If withdrawal symptoms improve, you may continue this dose on day two 
  • If withdrawal symptoms do not improve, you may take a second or third dose on that first day
what if you being suboxone treatment too early

What Happens if You Begin Suboxone Treatment Too Early?

It is important to wait until your last opioid dose completely metabolizes out of your body before beginning Suboxone treatment. This is because buprenorphine binds more strongly to opioid receptors in the brain than other opioids. It can therefore replace other opioids on the receptors in your brain too quickly and trigger withdrawal.[4]

Precipitated withdrawal is the rapid onset of withdrawal symptoms that can occur by taking Suboxone too soon after taking other opioids. Symptoms of precipitated withdrawal include pain, nausea, anxiety, goosebumps, and physical and emotional discomfort.[5]

Precipitated withdrawal occurs in about 9% of patients taking buprenorphine inductions, almost always because the individual is too impatient to relieve the withdrawal symptoms that occur when their body hasn’t had opioids, and they take their Suboxone too soon. Opioid withdrawal symptoms are not dangerous or life threatening, but they can be extremely unpleasant and uncomfortable. Therefore, be sure you communicate closely with your doctor and understand the instructions for starting Suboxone prior to initiating your first dose! If done appropriately, Suboxone can be a truly life saving medication for those with opioid use disorder.

SOURCES

  1. Clinical Opiate Withdrawal Scale. National Institute on Drug Abuse (NIDA). https://nida.nih.gov/sites/default/files/ClinicalOpiateWithdrawalScale.pdf. June 2003. Accessed February 2022.
  2. National Practice Guideline for the Use of Medications in the Treatment of Addiction Involving Opioid Use. American Society for Addiction Medicine (ASAM). https://www.asam.org/docs/default-source/practice-support/guidelines-and-consensus-docs/asam-national-practice-guideline-supplement.pdf. June 2015. Accessed February 2022. 
  3. A Patient’s Guide to Starting Buprenorphine at Home. American Society for Addiction Medicine (ASAM). https://www.asam.org/docs/default-source/education-docs/unobserved-home-induction-patient-guide.pdf?sfvrsn=16224bc2_0. Accessed February 2022.
  4. Suboxone Sublingual Tablets. Medsafe, New Zealand Government. https://www.medsafe.govt.nz/Consumers/cmi/s/suboxone.pdf. July 2021. Accessed February 2022.
  5. Managing Opioid Withdrawal Precipitated by Buprenorphine With Buprenorphine. Drug and Alcohol Review. https://onlinelibrary.wiley.com/doi/full/10.1111/dar.13228. January 2021. Accessed February 2022. 

Elena Hill, MD, MPH

Elena Hill, MD; MPH received her MD and Masters of Public Health degrees at Tufts Medical School and completed her family medicine residency at Boston Medical Center. She is currently an attending physician at Bronxcare Health Systems in the Bronx, NY where she works as a primary care physician as well as part time in pain management and integrated health. Her clinical interests include underserved health care, chronic pain and integrated/alternative health.

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