Suboxone Withdrawal and Detox

Suboxone is an unusual but useful medication that should only be used under the supervision of a licensed prescriber. 

Understanding Suboxone Withdrawal and Detox

Suboxone is an increasingly popular drug used in helping people make the difficult transition from opioid dependence to recovery. The medication reduces opioid withdrawal symptoms and cravings by activating opioid receptors in the brain without producing a high.

Suboxone contains the synthetic partial opioid-agonist buprenorphine and the opioid antagonist (blocker) naloxone (Narcan).

Clinical studies have shown that buprenorphine is can be an effective adjunct for helping prevent relapse, and has been associated with a number of positive trends, including:

• Reduced mortality
• Reduced relapse rates
• Reduced HIV and Hepatitis C transmission rates
• Improved outcomes in pregnancy
• Improved retention within recovery programs
• Improved quality of life

Naloxone is added to buprenorphine in Suboxone in order to prevent abuse of the drug by intravenous (IV) injection.

Can You Withdraw from Suboxone?

Although Suboxone is used to help people get through the detox period of opioid cessation, it can itself produce a withdrawal syndrome. As the opioid in Suboxone is cleared from the body following discontinuation, withdrawal effects typical of opioid withdrawal may also develop.

One way to prevent a withdrawal syndrome is by avoiding any sudden discontinuation of Suboxone. When people are ready to discontinue their treatment with Suboxone, their prescriber will help them put together a plan to taper off the medication gradually.

Suboxone Withdrawal Symptoms

The most substantial Suboxone withdrawal symptoms occur in the acute phase. This is the period in which withdrawal symptoms first occur after discontinuation of the drug until they taper off. However, some symptoms may persist for some time after the acute phase.

Although Suboxone withdrawal symptoms and timeline are generally fairly consistent, but there are some individual factors that may cause differences in the severity and duration of symptoms between different people. These factors include individuals’:

• Age
• Gender
• General health
• Liver and kidney function
• Genetic and biological make-up
• Concurrent use of other drugs
• Co-occurring mental health disorder (if any)
• Use of medically assisted detox, medications to treat withdrawal symptoms
• Duration of Suboxone use and dose used
• Number of previous attempts at detox
• The rate at which the drug was tapered down and stopped

Suboxone withdrawal symptoms can be physical and psychological in nature.

Physical Withdrawal Symptoms

Physical symptoms dominate the acute phase of withdrawal, but usually resolve themselves once the acute phase has ended. If Suboxone has been discontinued abruptly the symptoms can be severe for some people, and they can look and feel very sick. Typical physical Suboxone withdrawal symptoms include:

• Dilated pupils in the eyes
• Diaphoresis (intense sweating)
• High blood pressure, rapid heart rate, heart palpitations
• Shaking, hot and cold chills, Goosebumps (piloerection)
• Diarrhea, sometimes intense
• Muscle aches, twitching
• Fatigue, lethargy
• Insomnia
• Runny nose
• Loss of appetite
• Yawning

Psychological Withdrawal Symptoms

Psychological symptoms tend to be more of a challenge in the weeks or months after the acute withdrawal phase. However, although the physical symptoms dominate during the acute phase, some psychological symptoms are often present as well, such as:

• Intense cravings
• Anxiety
• Depressed mood
• Irritability, agitation
• Relapse dreams

The psychological symptoms during acute withdrawal and afterwards are an especially potent cause of relapse. This underlines the importance of getting proper treatment and rehab for substance addictions, because these symptoms and their underlying causes are directly addressed by addictions treatment programs.

Post-Acute Withdrawal Syndrome

Post-acute withdrawal syndrome (PAWS) refers to a lingering collection of symptoms that may persist following acute withdrawal, often lasting for a year or more. Many of the symptoms of PAWS are simply acute withdrawal symptoms that last longer than the usual duration, especially:

• Anxiety
• Sleep disturbances
• Depressive symptoms
• High blood pressure and heart rate
• Low energy, fatigue, apathy

While PAWS is predominantly associated with alcohol use disorder (AUD), it can occur following withdrawal from other drug use as well. However, more commonly, prolonged post-acute withdrawal from Suboxone is instead simply known as protracted withdrawal symptoms. These may last weeks or months from the last drug use. The symptoms tend to be primarily psychological and may include:

• Anxiety
• Depression
• Fatigue, lethargy (often related to depression)
• Relapse dreams
• Anhedonia (inability to experience pleasure)
• The “pink cloud” syndrome (excessively happy feelings, ignoring the reality of life)
• Negative feelings typical of addiction: guilt, remorse, self-loathing, low self-esteem and anger
• Emotional blunting
• Irritability
• Difficulty concentrating

People who experience such protracted symptoms should seek medical attention, because most are treatable.

Can You Die from Suboxone Withdrawal?

Withdrawal from Suboxone on it own is rarely itself fatal. Although Suboxone withdrawal can be an extremely unpleasant experience for many, it doesn’t kill them. However, there have been people who have died from opioid withdrawal, mainly because they became dehydrated and electrolytes in their blood went awry from the vomiting and diarrhea.

These cases have nearly all been from people who suddenly stopped their opioid (usually heroin) and withdrew on their own without any medical care, most often in a jail setting (only 10-12% of U.S. county jails have drug detox services available).

As such, the threat of death from Suboxone withdrawal is small, and exists primarily in people who were abusing Suboxone and/or other drugs and suddenly stopped their drug use without any medical detox care.

How Long Does Suboxone Withdrawal Last?

The Suboxone withdrawal timeline is based on buprenorphine, which has a long half-life (28-37 hours when dissolved under the tongue). This is the time it takes the body to remove ½ of the drug from the blood.

It usually takes 3-5 days before enough of the drug is removed from the body to produce withdrawal symptoms, but withdrawal symptoms may occur within 24 hours for some people, depending on individual factors. Withdrawal usually resolves by about seven days. Protracted withdrawal symptoms, when they occur, may last weeks to months.

Suboxone Withdrawal Treatment

The best Suboxone withdrawal symptoms treatment is proper downward taper off the medication under the supervision of a prescriber who is familiar with Suboxone detox, or under the care of a detox facility. People can be tapered off their medication according to how their body reacts to the dose changes, rather than according to a pre-set schedule.

Even with a proper taper, there may be some Suboxone withdrawal, and there are medication options for helping people through these symptoms, such as:

• Clonidine and lofexidine are an older type of blood pressure medication that has been found to reduce some withdrawal symptoms. However, they are also fraught with side effects; most notably it can cause low blood pressure and slow heart rate, sedation, and insomnia. As well, when stopped, they can cause rebound high blood pressure and rapid heart rate. As such, these medications are used with great care and usually only on an in-patient basis.
• Anti-diarrhea medications: there are a number of options, some of which contain narcotics and should therefore be avoided
• Buspirone (Buspar): this older anti-anxiety medication is effective for treating opioid withdrawal symptoms. One small studyfound Buspar to be as effective as a methadone taper for alleviating opioid withdrawal symptoms
• Zopiclone or eszopiclone (Lunesta): these are useful medications for treating withdrawal-related insomnia. They are not affected by benzodiazepine tolerance
• Benzodiazepines: may be used for agitation, anxiety or insomnia
• Acetaminophen (Tylenol): for muscle aches and headache

As well, it is important to identify and treat any underlying mental health disorder, as these are present in more than half of people with substance addictions. An untreated mental health disorders may worsen the experience of withdrawal, especially the protracted symptoms.

How Is Suboxone Used During Withdrawal?

When Suboxone is used as a treatment for withdrawal from chronic opioid use, it is used after treatment induction (initiation) with Subutex, which contains buprenorphine but not naloxone.

The maintenance dose of Suboxone is determined by subjective reporting of symptoms by the patient, since there is no blood test that can guide therapy. This is usually done using a validated questionnaire, most commonly the Clinical Opiate Withdrawal Scale (COWS).

Opioid and Heroin Withdrawal

Withdrawal from opioids (including heroin) can be successfully managed using Suboxone following induction with Subutex. The only other FDA-approved opioid that can be used to treat opioid withdrawal is methadone, another long-acting synthetic opioid.

Suboxone is more expensive than methadone but it has a better side effect profile and is six times less likely to cause an overdose compared to methadone. As well, Suboxone can be administered from a physician’s office, unlike methadone, which must be dispensed via specially licenced methadone clinics that may have long waiting lists and other barriers to access.

Suboxone has been shown to be as good as methadone, better than naloxone therapy alone, and better than abstinence-only for treatment retention and maintenance of recovery in the short term. Suboxone has less abuse potential than methadone and can be tapered off more quickly.

Precipitated Withdrawal

Buprenorphine has such a strong affinity for opioid receptors that it will actually displace other opioids. Buprenorphine binds to opioid receptors much more firmly than does naloxone, but naloxone nevertheless increases the effect of displacing opioids from their receptors.

Since buprenorphine is only a partial opioid agonist, it has a much weaker opioid effects than do other opioids. Suboxone therefore causes sudden withdrawal from opioid effects when it is taken in someone who has not yet detoxed from opioid use. As such, Suboxone precipitated withdrawal may occur if the drug is started too early.

Finding a Detox Center

Undergoing medically assisted detox at an accredited facility is the safest and most effective way to rid the body of opioids and other substances and transition smoothly into treatment and recovery. This process gives the body a chance to properly ease from drug use back to normal health and function without the shock of sudden withdrawal.

When people detox from opioid or other drug use at The Recovery Village Columbus, our team of addictions professionals provide the care and expertise for a safe withdrawal in a supportive environment. If you wish to discuss opioid addiction in yourself or a loved one please feel free to contact us for a confidential discussion with one of our staff.