Understanding Precipitated Withdrawal

The opioid epidemic is one of the most critical health crises in the United States. Every year, over 100,000 people die from drug overdose in the U.S., the vast majority of which were fully or partially caused by opioids.

Luckily, recent years have seen medications like naloxone and buprenorphine grow in popularity and availability, which have dramatically cut down on the number of opioid overdose fatalities. However, these medications can also cause some problems on their own, including precipitated withdrawal.

What is precipitated withdrawal? And what can you do to avoid it? Read on to find out.

What Is Precipitated Withdrawal?

Precipitated withdrawal is like typical opioid withdrawal, but the cause is different. Precipitated withdrawal is brought on by an opioid addiction treatment medication, whereas typical opioid withdrawal is brought on by reducing or stopping your opioid intake after prolonged or heavy use.

Although each medication that causes precipitated withdrawal functions differently, all of them can make the body think that there are no more opioids left, which then causes the unpleasant symptoms of withdrawal.

Precipitated withdrawal is often an uncomfortable and frightening experience for those who go through it. Not only is withdrawal highly unpleasant on its own, but precipitated withdrawal can come on suddenly, often within minutes of the medication being administered. It also worsens in severity much faster than what is typical of normal withdrawal.

Precipitated withdrawal is most typically caused by medications containing naltrexone, naloxone, and/or buprenorphine. Examples of medicine brands that may cause precipitated withdrawal include:

• Vivitrol
• Narcan
• Suboxone
• Zubsolv
• Bunavail
• Subutex
• Sublocade

Precipitated Withdrawal Risks

If you or a loved one is trying to quit opioids, you should do so with a doctor’s guidance since there are potential risks you run during the process, especially with precipitated withdrawal:

• Intensity of symptoms: The onset of symptoms and the speed with which they increase in severity is more intense than typical withdrawal. This may lead to severe physical and psychological discomfort.
• Increased stress on the body: The sudden onset of precipitated withdrawal places additional stress on the body, which can cause cardiovascular complications, elevated heart rate, and increased blood pressure.
• Psychological distress: Precipitated withdrawal can cause significant psychological distress, including anxiety, agitation, and intense panic.
• Potential for complications: Precipitated withdrawal can cause physiological and psychological complications, especially for those with pre-existing conditions or underlying health issues.
• Increased risk of relapse: The unpleasantness of precipitated withdrawal can motivate relapse as patients attempt to relieve symptoms.
• Gastrointestinal issues: Precipitated withdrawal can cause nausea, vomiting, diarrhea, and other forms of gastrointestinal distress, which may lead to dehydration or electrolyte imbalances.
• Cardiovascular and respiratory issues: The cardiovascular and respiratory issues that precipitated withdrawal can lead to heart failure, heart attack, and other serious complications.
• Mental health concerns: Precipitated withdrawal can cause severe distress that can exacerbate existing health concerns or cause depression and suicidal thoughts that can put individuals at greater risk of self-harm and suicide.
• Potential for agitation and violence: Agitation and irritability are common symptoms of precipitated withdrawal that may escalate into aggressive or violent behavior.

Please be aware that you should seek immediate medical help if you experience any of the above symptoms.

Preventing Precipitated Withdrawal

Preventing precipitated withdrawal is critical when helping patients transition from opioids to buprenorphine or other similar treatments. Luckily, there are ways to reduce the risk of precipitated withdrawal or minimize its severity if it does occur.

“To prevent precipitated withdrawal when transitioning between opioids, tapering slowly is key, as is waiting until moderate withdrawal sets in before starting replacement medication,” says psychiatric mental health nurse practitioner (PMHNP) Valerie Puffenberger.

As the person who is quitting opioids, the best thing you can do is seek help from a medical professional. This could be your primary care provider, a doctor at a drug rehab, or staff at an emergency room or urgent care.

The doctor helping you will assess your opioid use history, including which opioids you used and how much time has passed since your last use. They’ll also record your overall health, medical history, and pre-existing health conditions.

Once they’ve gathered basic information, your doctor will use the Clinical Opioid Withdrawal Scale (COWS) or a similar assessment tool to measure the severity of withdrawal symptoms and guide the timing and dosage of opioid addiction treatment medication.

Generally, it’s best to start with lower doses of the medication and then increase, if necessary, after observing the reaction to the lower dose. This is sometimes known as microinduction.

It may sound counterintuitive, but ideally, patients will already be experiencing mild to moderate withdrawal symptoms before medication is administered. This is because waiting until withdrawal symptoms are present minimizes the risk of precipitated withdrawal.

Treating Precipitated Withdrawal

Although precipitated withdrawal can be very unpleasant and, in some situations, potentially dangerous, there are numerous treatments that can alleviate symptoms or even eliminate them entirely.

“It can be extremely uncomfortable mentally and physically, so having medical supervision and social support is highly advisable,” says Puffenberger. “Stay strong. The acute phase tends to resolve within 72 hours.”

Precipitated withdrawal treatments can be loosely divided into immediate interventions and medication-based approaches.

Immediate interventions used to treat precipitated withdrawal include:

• Stopping administration of the medication that is causing precipitated withdrawal immediately
• Providing supportive care, including reassurance, a calm environment, and verbal support
• Hydrating the patient by providing fluids, especially water and those with high electrolyte levels
• Continuously monitoring vital signs, especially heart rate, blood pressure, respiratory rate, and temperature

Medication-based approaches to treating precipitated withdrawal include:

• Carefully administering a short-acting opioid to alleviate withdrawal symptoms
• Buprenorphine titration, or starting with a low dose and gradually increasing it
• Clonidine can be administered to address hypertension, anxiety, and restlessness
• Non-opioid analgesics can be used to provide pain relief
• Benzodiazepines can be used to address anxiety and agitation
• Symptom-specific medications can be used for specific symptoms — for example, antiemetics for nausea and vomiting and antidiarrheals for diarrhea

Recovery and Long-Term Support

The best way to achieve long-term recovery from opioid use is to seek out professional help for opioid addiction or withdrawal.

There are thousands of opioid treatment programs throughout the country. Medically supervised detox programs help patients get through withdrawal safely and comfortably. Both inpatient and outpatient rehab programs help patients uncover the underlying causes of their addictions and identify their triggers and healthy coping mechanisms. Addiction counselors and therapists can help patients explore their emotions and feelings and then help them change their thought patterns and behaviors.

Finding and participating in support groups and long-term counseling is also critical for long-term opioid recovery. Support groups, like Narcotics Anonymous (NA) and Heroin Anonymous (HA), provide a sense of community and belonging, along with support, advice, guidance, and a sense of purpose. Millions of former opioid users rely on support groups to stay sober every year.

Long-term counseling is also critical, even after many years of sobriety. Counselors can help patients identify warning signs they may have missed, provide additional training and guidance, and help treat mental health conditions that may be underlying causes of addiction.

Another critical aspect of long-term recovery from opioid use is to create and follow a relapse prevention plan, which should include:

• All known triggers and possible coping strategies
• A list of supportive friends, family, and medical professionals that can provide support
• An emergency response component that details what the individual will do in cases where they are unable to avoid a possible trigger or are put under unusual duress
• Healthy lifestyle changes, including alternatives to substance use like hobbies and activities, regular check-ins with professionals, and realistic goals

By Your Side Every Step of the Way

Opioid addiction is one of the hardest substance use disorders to recover from, and it may seem like an impossible task. However, nothing could be further from the truth. Every year, thousands of people successfully overcome opioid addiction and begin a meaningful life of sobriety.

More importantly, you don’t have to do it alone. Legacy Healing Center is here to help you or your loved one heal from opioid use. We’ll be by your side every step of the way, from withdrawal to long-term recovery.

Call 888-534-2295 today to speak with a treatment staff member about how we can help you find the path to a better life.

Precipitated Withdrawal FAQs

What is precipitated withdrawal?

Precipitated withdrawal is withdrawal that is induced by an opioid treatment medication. It is most commonly seen in cases where a drug containing naloxone, naltrexone, or buprenorphine is given to an individual with an opioid use disorder. Precipitated withdrawal comes on much faster than typical withdrawal, and, in some cases, the symptoms might be more intense.

How to stop precipitated withdrawal?

Precipitated withdrawal can be stopped in several ways. In some cases, it may be appropriate to administer an opioid to relieve symptoms. In other cases, other medications may be used to relieve specific symptoms, like nausea or anxiety. However, in most cases, precipitated withdrawal will resolve on its own without medical intervention, though the process might be extremely unpleasant.

Although precipitated withdrawal can be treated, it is much more effective to prevent it. Precipitated withdrawal can be prevented with proper medication administration techniques that your doctor determines and oversees.

What are the symptoms of precipitated withdrawal?

Every case of precipitated withdrawal is unique, and what symptoms appear depends on a large number of factors, including the specific opioids used, the length and severity of the addiction, and the patient’s biology and genetics. However, some of the most common symptoms include:

• Increased heart rate (tachycardia)
• Elevated blood pressure (hypertension)
• Intense anxiety, restlessness, and sense of panic
• Agitation and irritability
• Aggressive or violent behavior
• Nausea and vomiting
• Abdominal cramps and diarrhea
• Muscle aches and pains
• Excessive sweating
• Pupil dilation (mydriasis)
• Flu-like symptoms, including runny nose and sneezing
• Chills and goosebumps
• Insomnia and other sleep disturbances

Can Sublocade cause precipitated withdrawal?

Yes, Sublocade can cause precipitated withdrawal. Sublocade contains buprenorphine, which, when administered improperly, can cause precipitated withdrawal. To avoid precipitated withdrawal, Sublocade should only be administered after withdrawal symptoms have already appeared. Sublocade titration, or starting with a lower dose and then gradually raising it, can also prevent Sublocade-induced precipitated withdrawal.

How long does precipitated withdrawal last from Suboxone?

The length of time that precipitated withdrawal from Suboxone lasts is determined by many factors and will vary from person to person. In general, the precipitated withdrawal symptoms will subside when the Suboxone leaves the system. The half-life of buprenorphine is approximately 24 to 60 hours, meaning that most individuals will see precipitated withdrawal symptoms end within a few days to a week.

About the Author

Jeffrey Juergens

Jeff Juergens is a leading author in the addiction and recovery field, dedicating the last seven years of his life to helping those struggling with substance use issues find the help that they need. Jeff's work has been used in rehabs across the country as tools to help patients achieve sobriety.

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Dr. Olushola, MSW

Olushola Lawal, MSW, RCSWI Olushola (Shola) Lawal serves as a Primary Therapist at Legacy Healing Detox. Shola was born and raised in South Florida. He is a Florida State University double alumnus graduating with his Bachelor of Social Work in 2013 and his Master of Social Work in 2015. Shola’s...

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