How Long Does Precipitated Withdrawal LastAnna Ciulla
Addicted or dependent on prescription painkillers, heroin, or other opiates? While you may be eager to get treatment to overcome such dependence or addiction, fear about what you’ll experience in the way of withdrawal symptoms may be a factor holding you back. The truth is that no one discontinues opiates – especially after chronic or long-term use – without going through withdrawal. The safest and most effective way to deal with withdrawal and precipitated withdrawal is to seek professional addiction detox and treatment. Opiate withdrawal can happen gradually over a few days or weeks while the body detoxes (rids itself) of the opiates and begins the process of readjustment. Certain medications such as buprenorphine and naltrexone used as opiate replacement therapy can either speed up or worsen the withdrawal process if incorrectly used.
WHAT IS PRECIPITATED WITHDRAWAL?
Among the definitions of precipitated withdrawal is one from the National Alliance for Advocates of Buprenorphine Treatment (NAABT), which describes precipitated withdrawal as “the rapid and intense onset of withdrawal symptoms initiated by a medication.”
WHAT CAUSES PRECIPITATED WITHDRAWAL?
In essence, the accelerated onset of withdrawal symptoms precipitated withdrawal occurs when medication-assisted treatment (MAT) is begun without sufficient time lapse from the last dose of opiates or prescription painkillers and the first medication dose administered to treat opiate addiction.
Suboxone is a highly-effective medication used in the treatment of opiate addiction and dependency. The medication contains buprenorphine, a partial opioid agonist, and naloxone, the overdose-reversing drug. Suboxone binds to the opiate receptors in the brain while not stimulating those receptors as strongly as the narcotics it’s replacing. With suboxone, there’s not the same type of euphoria triggered that a user gets from heroin and other opiates. Yet suboxone does help ease withdrawal symptoms and eliminate drug cravings.
While this is positive for the individual undergoing opiate discontinuation treatment, there is a crucial point to consider about the timing. The individual cannot start suboxone until they are already experiencing opiate withdrawal symptoms that are mild to moderate. Otherwise, suboxone will dislodge the remaining opiates off the individual’s brain receptors and the person will immediately go into severe withdrawal.
In addition, when an individual is taking suboxone, it’s important to take it exactly as prescribed and directed. Taking too much of it, abusing it or diverting suboxone can bring about precipitated withdrawal. Mixing alcohol and other drugs with suboxone can also cause precipitated withdrawal.
Research on the use of extended-release naltrexone (Vivitrol®), a medication approved by the Food and Drug Administration (FDA) for therapy to prevent relapse for opiate and alcohol abuse, showed “amplified” severe risk of precipitated opioid withdrawal when precipitated by a long-lasting opioid antagonist. Among the recommendations are that providers adhere to manufacturers’ warnings and clinical protocols to include a naloxone challenge – and to make sure there’s an adequate opiate-free period before starting Vivitrol therapy.
WHAT ARE THE SYMPTOMS OF PRECIPITATED WITHDRAWAL?
When a person who is addicted to opiates or has opiates in his or her body and abruptly goes off them, the body is unable to adjust to this sudden opiate cessation. As a result, the body then goes through a number of symptoms of withdrawal that can be unpleasant. These withdrawal symptoms include cramping, dilated pupils, fever, insomnia, muscle aches and pains and sweating.
However, someone who is a chronic (long-term) heroin or opiate user who’s now significantly physically dependent on the opiate, may experience severe withdrawal symptoms. Among these are depression, diarrhea, high blood pressure, rapid heartbeat, and suicidal thoughts.
It is important to note that in individuals who have a high tolerance to heroin or other opiates, buprenorphine (in suboxone), although suboxone is a preferred treatment for getting off opiates, may still precipitate withdrawal symptoms. Buprenorphine, a partial opioid agonist, even though it is medication-assisted treatment for opiate dependence and addiction, is itself still an opioid – and is used to help mitigate withdrawal symptoms in those with significant dependence on opiates.
The symptoms of precipitated withdrawal can occur quickly and become intense. According to clinical recommendations, the client should already be in either mild or moderate withdrawal before they receive their first dose of buprenorphine. In no instance should someone high on opiates be given buprenorphine.
The safest time to begin administering buprenorphine is when the doctor or clinician assesses the client’s symptoms and notes a minimum score of 5 or 6 on the COWS (Clinical Opiate Withdrawal Scale).
COWS – CLINICAL OPIATE WITHDRAWAL SCALE
There are 11 items on the clinical opiate withdrawal scale (COWS). It is basically a flowsheet to measure the most typical symptoms associated with opiate withdrawal over a period of time. Doctors and clinicians use the COWS to help assess opiate addiction in the individual. Symptoms included on the COWS are:
- Resting pulse rate: record of beats per minute
- Sweating: over the past half hour, not related to room temperature or client activity
- Restlessness observation during the assessment
- Pupil size
- Bone or joint aches if an individual was having pain previously – only additional component pertinent to opiate withdrawal is scored
- Runny nose or tearing not attributed to symptoms of cold or allergies
- Gastrointestinal upset: over the last half hour
- Tremor observation of outstretched hands
- Yawning observation during an assessment
- Anxiety or irritability
- Gooseflesh skin
Each item is rated with a number. Scores of 5-12 are consistent with withdrawal symptom that are mild; scores between 13-24 equal moderate withdrawal symptoms; 25-36 equals moderately severe symptoms of withdrawal, and more than 36 shows severe withdrawal symptoms.
HOW LONG DOES PRECIPITATED WITHDRAWAL LAST?
Symptoms of precipitated withdrawal can develop quite rapidly. In the case of suboxone, precipitated withdrawal symptoms can start within 1 to 2 hours of receiving the first dose of the medication. These symptoms are usually short-lived and resolve in a matter of a few hours or a day or longer.
In the case of naltrexone, precipitated withdrawal can begin within minutes and can last as long as 48 hours. As with suboxone withdrawal symptoms, those associated with naltrexone are generally short-lived – averaging about 30 to 60 minutes.
HOW DO YOU STOP PRECIPITATED WITHDRAWAL?
Suboxone – which contains both buprenorphine and naloxone, the latter a drug that temporarily stops overdose symptoms while someone in opiate overdose can get emergency medical assistance – may stop precipitated withdrawal for a short period of time, a few hours. Suboxone will not completely stop withdrawal, though.
An important point about precipitated withdrawal is that it is not usually life-threatening, although someone experiencing precipitated withdrawal may need to be hospitalized, even requiring intensive care in severe cases.
Timing and care for precipitated withdrawal after an initial dose of suboxone may entail a doctor or clinician administering additional suboxone doses. In so doing, this may be sufficient to stop withdrawal symptoms. Supportive care may include typical treatments such as administering intravenous fluids, medications to curb nausea, sedatives, and other medications prescribed by the attending physician. If extreme agitation occurs, heavier sedation or anesthesia may be administered.
Interestingly, a 2017 study in the Journal of Ethnopharmacology pointed to some success with an alkaloid-rich plant extract, Mitragyna speciosa, in attenuating the severity of symptoms of naloxone-precipitated morphine withdrawal in mice. Researchers concluded that the use of M. speciosa extract may be useful in an opiate addiction treatment program.
HOW CAN YOU AVOID PRECIPITATED WITHDRAWAL?
Dosing with buprenorphine by an experienced treatment team may prevent precipitated withdrawal in an individual who has a high tolerance to full opiate agonists such as heroin. On the other hand, the larger the buprenorphine doses in such individuals, the more intense precipitated withdrawal will be for him or her – if there is any full agonist still active in the body. The treating medical professional may instead safely administer small buprenorphine doses.
Keep in mind that you must be honest with your drug detox and treatment team about the last time you used opiates. If the window is too short, you risk going into precipitated withdrawal. As soon as you begin to experience any of precipitated withdrawal symptoms, contact your doctor or treatment team and seek immediate medical assistance.
When the goal is overcoming addiction to opiates, the best advice is to seek professional treatment from a drug and alcohol rehab facility that uses the latest evidence-based MATs and treatment therapies. Look for a treatment facility that has full drug and alcohol detox and treatment capabilities on-site and one that specializes in treating opiate addiction or dependence. The medical staff will help ensure that any opiate withdrawal, including precipitated withdrawal, that you experience will be addressed with the most proven medications and treatment – and give you the confidence that you’re in the best hands to get you started on your recovery journey.
For more about opiate addiction, withdrawal, detox, treatment, and recovery, check out these articles:
How Does Suboxone Work?
Drugs.com. “Suboxone.” Retrieved from https://www.drugs.com/pro/suboxone.html
Journal of Ethnopharmacology. “Effects of alkaloid-rich extract from Mitragyna speciosa (Korth.) Havil. on naloxone-precipitated morphine withdrawal symptoms and local field potential in the nucleus accumbens of mice.” Retrieved from https://www.ncbi.nlm.nih.gov/pubmed/28687506
National Alliance of Advocates for Buprenorphine Treatment. “Precipitated Withdrawal. What it is. How to avoid it.” Retrieved from https://www.treatmentmatch.org/_docs/NAABT_PrecipWD.pdf
Psychopharmacologia. “Development of physical dependence on morphine in respect to time and dosage and quantification of the precipitated withdrawal syndrome in rats.” Retrieved from https://link.springer.com/article/10.1007/BF00428791
Psychopharmacologia. “Role of catecholaminergic mechanisms in the expression of the morphine abstinence syndrome in rats.” Retrieved from https://link.springer.com/article/10.1007/BF00440843
The American Journal of Emergency Medicine. “Severe opioid withdrawal precipitated by Vivitrol®.” Retrieved from https://www.ncbi.nlm.nih.gov/pubmed/29605483
The Journal of Pharmacology and Experimental Therapeutics. “Brain Sites of Precipitated Abstinence in Morphine-Dependent Rats.” Retrieved from http://jpet.aspetjournals.org/content/185/1/108.short
The Journal of Pharmacology and Experimental Therapeutics. “Quantitative Aspects of Precipitated Abstinence in Morphine-Dependent Rats.” Retrieved from http://jpet.aspetjournals.org/content/184/2/398.short