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January 27, 2019

How Long to Wait to Take Suboxone?

You want to get off opiates, but have some concerns about painful withdrawal symptoms that you’re likely to experience as prescription painkiller drugs or illicit opiates such as heroin leave your system. You may have already heard about Suboxone, a prescription medication approved by the Food and Drug Administration (FDA) in 2002 for the treatment of opiate addiction, or your doctor or medical professional may have recommended you start on it as part of opiate detox and drug rehab treatment. But do you know how long to wait to take Suboxone, so that you can avoid painful opiate withdrawal symptoms? This article will lay out the facts on the appropriate timeline for starting Suboxone maintenance therapy.

TIMING IS EVERYTHING: YOU MUST BE IN WITHDRAWAL FIRST

While Suboxone is effective in alleviating painful withdrawal symptoms, you can’t just start right in taking it. Indeed, if you prematurely take Suboxone while also taking methadone, hydrocodone, OxyContin or other narcotics, you’ll likely go into abrupt—and painful—withdrawal. That’s definitely not what you want to happen. Instead, according to recommendations from addiction treatment experts, you must already be in withdrawal before you can safely begin Suboxone.

That said, you don’t need to be in such severe withdrawal—violent diarrhea, vomiting, cramping or other painful symptoms—before Suboxone is initiated. The presence of mild withdrawal symptoms, including cravings, may mean that it’s safe for to start you on Suboxone. Of course, your prescribing physician or drug rehab treatment professional is the one who’ll make that determination.

CLINICAL OPIOID WITHDRAWAL SCALE (COWS)

How do they know? Doctors who prescribe Suboxone use the Clinical Opioid Withdrawal Scale (COWS) to score their patients to determine their readiness to begin taking Suboxone. The doctor uses the scale to rate the presence and number of current symptoms. The recommended score is an accumulative 25-36 (moderately severe), with numbers assigned to each parameter, according to frequency/intensity/visible presence, etc. The parameters include:

  • Resting pulse rate (number of beats/minute)
  • Sweating (over the past 30 minutes)
  • Restlessness (observed during assessment)
  • Tremors (observation of outstretched hands)
  • Pupil size
  • Gastrointestinal upset (over the last 30 minutes)
  • Anxiety or irritability
  • Bone or joint aches (if pain experienced previously, the doctor tries to assess additional pain attributed to opioid withdrawal)
  • Yawning (observed during assessment)
  • Runny nose or tearing (not attributable to a cold or allergies)
  • Gooseflesh skin

Avoid letting fear prevent you from going forward with Suboxone maintenance therapy. You have to have confidence in your treatment professionals and that they will make the right decisions regarding your treatment given your particular circumstances, including the opiates and possibly other substances you’ve been using. They’re not going to allow you to suffer unnecessarily, or to experience prolonged and uncomfortable withdrawal symptoms. Besides Suboxone, there are other medications and treatments that can be prescribed to help alleviate and reduce some withdrawal symptoms.

HOW DO I KNOW HOW LONG TO WAIT BEFORE SUBOXONE CAN START?

To say that you must be in moderate to moderately severe withdrawal sounds like a lot. And, the fact is that the appearance of withdrawal symptoms will vary depending on what opiate you’ve been taking. A short-acting opiate such as Percocet or Vicodin might mean a wait time before your physician can prescribe Suboxone of 24 hours. But, for long-acting opiates, such as Oxycontin, you’ll likely have to wait at least 48 hours. For methadone, it could be as long as 72 hours.

There are many reports of people who’ve tried to come off opiates and have their doctor prescribe Suboxone too soon. That plunged them into very uncomfortable, even severe withdrawal. The general advice is to wait as long as you can before taking Suboxone, as the buprenorphine will better take hold and work. Too soon, and the Suboxone will not work properly. Besides, you’ll very likely experience nasty withdrawal, known as precipitated withdrawal. This type of withdrawal can also occur if you take too much Suboxone, abuse it or divert it for the purposes of getting high.

WHAT DOES SUBOXONE DO?

Suboxone is the registered brand name of a prescription medication used to help alleviate withdrawal symptoms of opiate dependence or addiction. The prescription medication contains buprenorphine, a partial opioid agonist, and naloxone, an opioid antagonist.

Suboxone is a partial agonist opiate medication, which means the buprenorphine occupies the brain’s opiate receptors yet does not cause the acute effects of narcotics. The naloxone, an opioid antagonist, works to reduce or diminish opiate cravings and withdrawal symptoms. Naloxone by itself, Narcan (naloxone HCL), is the life-saving medication carried by emergency healthcare professionals and first-line responders in order to reverse the effects of an opiate overdose. According to the Narcan website, someone overdoses on opiates approximately every 12 minutes.

The unique properties in Suboxone help it work to:

  • Lower the potential for misuse
  • Reduce the effects of physical dependence on opiates, including symptoms of withdrawal and drug cravings
  • Increase safety in the event of opiate overdose

While on Suboxone, you may get a mild feeling of euphoria, but it won’t be the intense high of the opiates you took previously. And, if you try to take too much of the medication in an attempt to increase the high, or take it more often than prescribed, you won’t increase the high. It will only level off. Many people say they don’t feel particularly well after taking too much Suboxone (in doses or frequency other than prescribed, or in a form they’ve gotten from a friend or on the street).

The reason you don’t want to take Suboxone while also taking other narcotics, including methadone, hydrocodone, or Oxycontin, for example, is that doing so can propel you into immediate and severe withdrawal. That’s because Suboxone binds tightly to brain receptors, more so than other narcotics, and taking both other opiates and Suboxone causes Suboxone to knock those narcotics off the brain receptors. It’s easy to see why the individual must already be in withdrawal before the treating physician or clinician can start them on Suboxone.

SUBOXONE USE IN MEDICATION-ASSISTED TREATMENT

Medication-assisted treatment (MAT) is considered the gold standard and the front line of defense in both detox from opiates (including prescription opiates) and in formal treatment following detox. One factor that may determine a person’s MAT plan will be what kind of opiate they were taking. The doctor may first start the person on a low buprenorphine dose and then increase the dosage for a day or two before transitioning to a medication with buprenorphine and naloxone. Again, depending on opiates taken, another option the doctor may choose is buprenorphine and naloxone treatment right away.

Suboxone Side Effects

Suboxone’s side effects are similar to the side effects of opiates and may include:

  • Constipation
  • Cramping
  • Cravings
  • Distress
  • Fever
  • Muscle aches and cramps
  • Nausea
  • Sleep problems
  • Vomiting

Do not take other sedatives, particularly benzodiazepines, while taking Suboxone. Doing so will produce an additive effect of sedatives, which may prove dangerous, even deadly. Grinding Suboxone and mixing with benzodiazepines to create an injectable solution has caused deaths. Other precautions include avoiding use of tranquilizers, antidepressants, or sedatives—unless directed by a doctor—and avoiding alcohol.

How Do You Take Suboxone?

Suboxone is a little different than other pill medications in that it is a sublingual tablet placed under the tongue. Another format is buccal film (Bunavail) that goes between the cheek and gum. Buprenorphine by itself comes as a sublingual tablet with the brand name of Subutex. How you’ll take Suboxone will be determined by your doctor or drug rehab treatment professional who will first determine the appropriate dose. You will take the prescribed medication usually once daily (or every other day, as appropriate for your situation and as your treatment provider feels is best). It’s best to take the Suboxone at the same time of the day, so that you don’t forget and remain in compliance with your daily Suboxone medication regimen.

Why is it important to take the medication exactly as prescribed? When you’re prescribed sublingual tablets, the medication must be placed under the tongue and allowed to completely dissolve. You are cautioned not to chew or swallow the tablets whole. Also, be sure not to eat or drink any liquids until the Suboxone is fully dissolved.

You can be confident that, when taken at the right doses and as prescribed by your treatment professional, Suboxone helps reduce withdrawal symptoms and cravings and partially blocks the effects of other opiate drugs. If you’re taking Suboxone as part of maintenance treatment for opiate addiction, the medication keeps your brain’s opiate receptors occupied and stays on those receptors for several days. That’s why other opiates (heroin, for example) are typically unable to attach to those receptors.

 SUBOXONE: A POWERFUL MAT FOR OPIATE ADDICTION

You must trust your treatment professional and drug rehab treatment team about the duration, dosage, timing and other details about the Suboxone you’ve been prescribed to treat your opiate addiction. Know that they will constantly monitor and adjust your treatment plan to meet your changing needs.

It is also important to keep in mind that you may at some point transition from one form of Suboxone to another, or transition to Suboxone from Subutex, or to a different MAT, under the careful guidance of your drug rehab treatment team. One of the newest forms of buprenorphine approved by the FDA for the treatment of OUD is Sublocade, a once-monthly subcutaneous injection of buprenorphine in MAT for moderate-to-severe OUD. This medication may or may not be appropriate for your needs.

Perhaps most important is the ongoing behavioral counseling and therapies you’ll participate in as part of your personalized comprehensive treatment plan to overcome opiate dependence and addiction. Recovery is much more than just detox and maintenance with Suboxone and other MAT medications. You will need to learn better-coping methods, healthier lifestyle behaviors, how to prepare and implement an effective relapse prevention plan, develop and maintain your support network and more.  

For more about Suboxone, addiction and recovery, check out these articles:

  1. Dangers of Long-Term Suboxone Treatment
  2. Suboxone Detox – Withdrawal Symptoms and Timeline
  3. Will Suboxone Show up in a Drug Test?  
  4. How Long Does Precipitated Withdrawal Last?
  5. Prescription Opiate Detox: What to Expect from Withdrawal and Recovery
  6. Addiction Recovery Tips: Key Components of a Healthy Recovery Lifestyle
  7. Why Medication-Assisted Treatment is Important for Opiate Addicts in Early Treatment
  8. Heroin Detox Guide

Sources:

Cochrane Database of Systematic Reviews. “Buprenorphine for managing opioid withdrawal.” Retrieved from https://www.ncbi.nlm.nih.gov/pubmed/28220474

Cochrane Database of Systematic Reviews. “Opioid agonist treatment for pharmaceutical opioid dependent people.” Retrieved from https://www.ncbi.nlm.nih.gov/pubmed/28447766

Cochrane Database of Systematic Reviews. “Supervised dosing with a long-acting opioid medication in the management of opioid dependence.” Retrieved from https://www.ncbi.nlm.nih.gov/pubmed/28447766

Contemporary Clinical Trials. “NIDA Clinical Trials Network CTN-0051, Extended-Release Naltrexone vs. Buprenorphine for Opioid Treatment (X:BOT): Study design and rationale.” Retrieved from https://www.ncbi.nlm.nih.gov/pubmed/27521809

Drugs.com. “Opioid Withdrawal Record (Induction Form). (Adapted from Clinical Opioid Withdrawal Scale). Retrieved from https://www.drugs.com/resources/opioid-withdrawal-record.pdf

Drugs.com. “Suboxone.” Retrieved from https://www.drugs.com/pro/suboxone.html

Food and Drug Administration. “FDA approves first monthly buprenorphine injection, a medication-assisted treatment option for opioid use disorder.” Retrieved from https://www.fda.gov/NewsEvents/Newsroom/PressAnnouncements/ucm587312.htm

Lancet. “Comparative effectiveness of extended-release naltrexone versus buprenorphine-naloxone for opioid relapse prevention (X:BOT): a multicentre, open-label, randomised controlled trial.” Retrieved from https://www.ncbi.nlm.nih.gov/pubmed/29150198

MedlinePlus. “Buprenorphine Sublingual and Buccal (opioid dependence).” Retrieved from https://medlineplus.gov/druginfo/meds/a605002.html

Narcan.com. “Here’s What Happens in an Opioid Overdose.” Retrieved from https://www.narcan.com/patients/what-is-an-opioid-overdose-emergency

National Institute on Drug Abuse. “Buprenorphine.” Retrieved from https://archives.drugabuse.gov/buprenorphine

National Institutes of Health. “Extended Suboxone Treatment Substantially Improves Outcomes for Opioid-Addicted Young Adults.” Retrieved from https://www.nih.gov/news-events/news-releases/extended-suboxone-treatment-substantially-improves-outcomes-opioid-addicted-young-adults

Psychology Today. “How is Suboxone Treatment Different Than Drug Abuse?” Retrieved from https://psychcentral.com/lib/how-is-suboxone-treatment-different-than-drug-abuse/?all=1

Substance Abuse and Mental Health Services Administration. “The Facts about Buprenorphine for Treatment of Opioid Addiction.” Retrieved from https://store.samhsa.gov/product/The-Facts-about-Buprenorphine-for-Treatment-of-Opioid-Addiction/SMA15-4442

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