Precipitated withdrawal can occur when an antagonist (or partial antagonist, such as buprenorphine) is administered to a patient dependent on full agonist opioids. Due to Buprenorphine's high affinity but low intrinsic activity at the mu receptor, it displaces agonist opioids from the mu receptors, without activating the receptor to an equivalent degree, resulting in a net decrease in agonist effect, thus precipitating a withdrawal syndrome.
It is a common misconception that the Naloxone in Suboxone initiates precipitated withdrawal. This is false. The Naloxone can only initiate precipitated withdrawal if injected into a person tolerant to opioids other than buprenorphine. Taken sublingually the Naloxone has virtually no effect.
How to avoid precipitated withdrawal:
The best way to avoid this condition is through patient education. The patient should be informed, prior to the induction appointment, of what precipitated withdrawal is and how they can avoid it. The patient who understands that under reporting last use puts him/her at high risk for rapid and intense onset of withdrawal syndrome, is more likely to accurately report last use. Ask the patient what their first few symptoms and signs of withdrawal have been in the past. Look for these S/S before administering the first dose at induction.
Precipitated withdrawal puts the patient at risk for concluding that Buprenorphine is ineffective, or the doctor may not know how to help, or both. Either situation leaves the patient in a precarious state physically and emotionally.
Begin the induction by assessing last use of all Opioids, short and long acting, objective and subjective symptoms and calculate a COWS score. If not in sufficient withdrawal explain that it is in the patients best interest to wait.
(Heroin, Crushed OxyContin, Percocet, Vicodin, Oxycodone)
Short- acting Opioids have a half life of approximately 8 hours or less. Prior to induction, patients must abstain from all short-acting Opioids for 12 to 24 hours and/or have objective withdrawal symptoms sufficient to produce a score of 5 to 6 on the COWS (Clinical Opiate Withdrawal Scale) such as dilated pupils.
Patients transitioning from methadone to Buprenorphine require a slow taper to 30mg./day of methadone, for at least one week. Last dose must be no less than 36 hours prior to induction. A minimal score of at least 5 to 6 on COWS is recommended.
OxyContin (taken orally)
Discontinue use for at least 24 hours prior to induction, with a COWS score of at least 5 to 6.
How to Treat Precipitated Withdrawal
If the patient experiences precipitated withdrawal, administer additional 2mg. to 4 mg. doses of Buprenorphine hourly, until symptoms dissipate.