What is Precipitated Withdrawal?

4 min read · 5 sections
Evidence-Based Care
Expert Staff

What is Precipitated Withdrawal?

Precipitated withdrawal is when withdrawal symptoms are caused by medications or MAT used in substance abuse treatment rather than absence or abstinence from the chosen drug of abuse. Examples of medications used in medication assisted treatment include:

  • Suboxone
  • Subutex
  • Naltrexone

Symptoms of Precipitated Withdrawal

This is where the danger of precipitated withdrawal arises. With buprenorphine’s strong receptor-binding affinity, when given to a person who is already addicted to heroin, the buprenorphine removes and then replaces the heroin molecules that have already attached to the person’s opioid receptors in the brain. As a result of this, the buprenorphine produces a significantly reduced opioid reaction (as it should). But the effect of millions of receptors being deprived of their full opioid agonist and instead being replaced by a partial opioid agonist (that, by design, has a weakened effect) can trigger withdrawal symptoms in the person.

When the body is forced to go without those drugs, it cannot adjust to the sudden deprivation, and it experiences a number of unpleasant effects as a result:

  • Muscle aches and pains
  • Fever
  • Cramping
  • Sweating
  • Insomnia
  • Dilated pupils

If the person has been using heroin for a long time and has developed significant physical dependence, the symptoms can be severe. They include:

  • Depression
  • Diarrhea
  • Suicidal thoughts
  • Rapid heart beat
  • High blood pressure

In those who have built up a high tolerance to heroin, the buprenorphine – while ostensibly good for them, as an alternative to heroin – can still induce withdrawal symptoms, despite the fact that buprenorphine is an opioid itself and intended to ease withdrawal in people with significant opioid dependence.

When Should I Withdrawal With Suboxone or Buprenorphine?

These medications may block the action of any previously used opioid remaining in the bloodstream. If given at the wrong time, these medications can thrust a person into immediate, full-blown withdrawal. As part of a medical detox regimen, these medications may be safely used after a person has committed to quitting their drug of abuse, and has entered into the early stages of opioid withdrawal.

The combination of buprenorphine and naloxone to simultaneously quell withdrawal symptoms, provide a ceiling to opioid effects to protect against addictive euphoria, and deter abuse attempts with Suboxone itself, seems like the perfect system of keeping the compulsion and craving to use stronger opioids at bay.

But Suboxone is a powerful drug in its own right, and the effect it has on a person who still has a physical or psychological dependence on heroin or some other dangerous narcotic can be a source of concern in itself. Patients and caregivers should be aware of the condition known as precipitated withdrawal, and doctors have to carefully judge when it is safe to start Suboxone treatment.


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On the Clinical Opiate Withdrawal Scale, the scores for each symptom should be entered when the assessment starts, and then at regular intervals after the first dose of buprenorphine. A score between 5 and 12 is consistent with mild withdrawal symptoms; between 13 and 24 shows moderate symptoms; 25-36 shows moderately severe withdrawal symptoms; and any score in excess of 36 indicates severe withdrawal symptoms.

The delicate balance of knowing when and how to properly administer buprenorphine is one reason why detoxification and withdrawal should never be attempted at home, or by people who do not have the medical training to help a patient through the process. In fact, the fear of precipitated withdrawal is why some people may choose not to seek out treatment for their opioid addiction; such apprehension is considered to be one of the fundamental dynamics of addiction.

However, the only way for a person to be in a position to overcome a psychological compulsion to abuse opioids is to break the physical compulsion, and that comes through detoxification. The best and safest place to go through the process is in a professional treatment center, where a doctor can assess the person’s full medical history, and guide the person through detoxification and withdrawal. After detox, the individual should continue with therapy and counseling for long-term opiate addiction rehabilitation.

How Long Should Suboxone Be Prescribed?

The length of time one stays on Suboxone depends on a number of different factors: how long the person has been addicted to narcotics; the types of narcotics; whether there is a family history of substance abuse; how well the patient responds to Suboxone; and how well the treatment is progressing (in terms of the patient being able to participate in the daily activities at a rehab center).

Writing in The Fix, the director of the Addiction Medicine Clinic at the University of California, Los Angeles says there is no easy way to predict the best length of time for a person to receive Suboxone treatment. It is possible that some opiate addicts may require Suboxone therapy for years.

Furthermore, Suboxone itself can be very addictive; The New York Times referred to it as “addiction treatment with a dark side.” It is a difficult drug to stop using, says The Fix, so much so that people may need to keep using it for years, in order to stave off its own withdrawal symptoms. That Fix article sums it up by asking why there is no official medical protocol to eventually have patients stop using Suboxone, pointing some fingers at a pharmaceutical industry that rakes in billions of dollars every year (Suboxone itself, a “blockbuster drug” in the words of The New York Times, made over $1.5 billion in sales in 2012).Notwithstanding the pervasive influence of Big Pharma, Suboxone can be an effective and useful drug in helping people overcome their abuse of heroin and other harmful opioids. But such is the complexity of addiction that Suboxone should be administered at the proper time, so as not to trigger its own withdrawal and unwittingly make a difficult process even harder.

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