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Buprenorphine Withdrawal: What Timeline Should You Expect?

Many people who have opioid use disorder receive buprenorphine to wean them off their dependence, but buprenorphine itself can become a drug of abuse. When it comes to buprenorphine withdrawal, you should know what kind of timeline to expect. Learn how the physical symptoms set in, how they lead to psychological symptoms, and how a good detox center can help you through the entire process.

Buprenorphine and Opioid Agonists

Buprenorphine is an opioid, but unlike heroin, fentanyl, or oxycodone, it is a partial opioid agonist. This means that its activation of the opioid receptors in the brain and central nervous system is only minimal compared to full opioid receptors, like heroin, fentanyl, and oxycodone. 

When a full opioid agonist attaches itself to a receptor, it triggers the receptor to its fullest possible amount, delivering overwhelming amounts of euphoria and analgesia in the shortest possible time. This is the mechanism by which full opioid agonists can be so powerfully effective and addictive.

For a partial opioid agonist like buprenorphine, the mechanism is not quite the same. The opioid receptors are only minimally activated, so everything is reduced. The euphoria is not as pronounced as that from heroin, for example; pain relief is not as strong, and the time of onset is notably longer and slower. This is by design. Buprenorphine being a partial opioid agonist reduces the chances of it being abused in the same way full opioid agonists are, according to the Substance Abuse and Mental Health Services Administration.

This is also is why it is used as a treatment for opioid addiction. It allows a patient to move to a less addictive opioid, still satisfying the craving for opioids without continuing with the more powerful alternatives. This is a factor when a person who is on buprenorphine goes without it. The physical and psychological withdrawal symptoms are not as pronounced as they are with full opioid agonists, and the craving for buprenorphine might be easier to control. 

Subutex and Suboxone

Buprenorphine is sometimes said in the same breath as the name Subutex, a brand name for generic buprenorphine. Regardless of the name, the administration of the drug is the same: tablets placed under the tongue (sublingual), which are allowed to dissolve.

Another name often used with buprenorphine is Suboxone, which is the brand name for the combination of buprenorphine and naloxone, an opioid antagonist. While a partial opioid agonist only partially activates opioid receptors, opioid antagonists block the receptors by preventing other opioids from binding to them via “competitive binding,” in the words of Pharmacy Times.

Naloxone is widely used as an overdose reversal drug, and it is bundled with buprenorphine to prevent its misuse. If the tablets are crushed and snorted or injected, the naloxone blocks the opioid molecules from activating the target receptors. 

However, when buprenorphine is taken by itself, it still has its own abuse potential. The medication has its own black market, either for its recreational use or for patients who are still struggling with their opioid addiction. People have fatally overdosed by misusing their buprenorphine (dissolving the film strips in water and injecting the solution into their veins, bypassing the digestive system and sending the opioid directly into the bloodstream). 

This has made buprenorphine the “addiction treatment with a dark side,” in the words of The New York Times because many people who misuse it believe it is a safer drug of abuse than the full opioid agonists they were receiving treatment for. When taken properly, buprenorphine is certainly safer than heroin or oxycodone, but when misused and abused, it can be no less deadly and addictive.

Buprenorphine Withdrawal: What to Expect

As an opioid, buprenorphine has withdrawal symptoms not entirely unlike those of heroin and other full opioid agonists; however, the symptoms tend to be much milder. There are the usual headaches, nausea, disruptions to sleeping patterns, mood swings, periods of depression and anxiety, and flu-like symptoms. 

With buprenorphine withdrawal, the first symptoms are usually felt after about 30 hours of the last dose compared to a much shorter six to 12 hours for heroin or oxycodone. Patients will experience pain in their muscles, runny eyes and sinuses, agitation, disruptions to their sleeping patterns, periods of depression and anxiety, and flu-like symptoms. The next wave of symptoms will come three days into the withdrawal process and will include nausea, diarrhea and vomiting, abdominal cramping, deep depression, and a desperate craving for more buprenorphine. 

The physical withdrawal symptoms for buprenorphine should subside after a month, although a patient who has outstanding health issues (either pre-existing or ones that developed as a result of the withdrawal) might continue to experience some discomfort. However, even this relief a month on can be deceiving; it is around this time that patients are most at risk for feeling the cravings for more buprenorphine or opioids, and relapsing will likely cause them to use opioids to an even greater degree than they had been.


Going back to misusing buprenorphine after the experience of withdrawal will likely deepen the dependence on the medication, so it is vital that individuals receive treatment and support after the physical symptoms appear to have vanished. 

The psychological withdrawal symptoms of buprenorphine misuse (the depression and the desire for more buprenorphine) can continue past the easing of the other physical symptoms. Even if the patient’s physical health recovers, it is very important that they receive support and counseling for the mental health effects of buprenorphine abuse. 

Treating Misuse and Withdrawal

Treating buprenorphine withdrawal can be carried out in an inpatient or outpatient setting. Which option is best is determined by the patient’s medical history, their unique physiology, and the nature of their buprenorphine misuse. For example, if the patient is taking buprenorphine to treat a pre-existing heroin or oxycodone problem, their doctor might slowly wean them off buprenorphine to give their body time to adjust to the diminishing opioid presence. Other partial opioid agonists, or long-acting opioid agonists, might be prescribed to help with this process. 

On the other hand, those who were abusing buprenorphine for solely recreational purposes might be encouraged to undergo full detoxification since there is no pre-existing addiction to a full opioid agonist. However, a person who is chronically dependent on their recreational buprenorphine might still qualify for a slow taper or other medication, if their doctor feels that they still need some form of maintenance therapy.

As the buprenorphine hold is loosened, patients will be encouraged to meet with more treatment professionals to address the mental health fallout of their abuse of the medication. Inpatient and outpatient clinics alike offer different forms of support to help patients continue the hard work of recovery. This can mean learning to cope without using buprenorphine for pain management, or developing skills and strategies to keep relapse at bay. 

These treatment plans are vital for long-term success. Without them, the chances of the person going back to buprenorphine (or even a full opioid agonist) increase significantly. Rehabilitation can be difficult, but it is what will help people manage their buprenorphine cravings for years to come. 

What to Look for in Buprenorphine Detox

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A good treatment program for buprenorphine withdrawal and treatment should include components of medication management, therapy (such as cognitive behavioral therapy), support groups (such as Narcotics Anonymous or a similar 12-step program), family therapy, and, if possible, housing and employment assistance. Other treatment programs might offer alternative (non-drug-based) treatment, recreational activities, or life skills training.

Individuals and their family members should look for a treatment program that allows for a customized plan to address their specific needs. The multifaceted approach can seem overwhelming, but a long-term plan for ongoing aftercare support will help individuals learn how to handle stress while simultaneously focusing on their recovery.

Sources

What’s This Agonist/Antagonist Stuff? The National Alliance of Advocates for Buprenorphine Treatment. Retrieved December 2018 from from https://www.naabt.org/faq_answers.cfm?ID=5

(May 2016). Buprenorphine. Substance Abuse and Mental Health Services Administration. Retrieved December 2018 from from https://www.samhsa.gov/medication-assisted-treatment/treatment/buprenorphine

(January 2018). Opioid Agonists, Partial Agonists, Antagonists: Oh My! Pharmacy Times. Retrieved December 2018 from from https://www.pharmacytimes.com/contributor/jeffrey-fudin/2018/01/opioid-agonists-partial-agonists-antagonists-oh-my

(May 2017). Use and Misuse of Opioid Agonists in Opioid Addiction. Cleveland Clinic Journal of Medicine. Retrieved December 2018 from from https://www.mdedge.com/ccjm/article/136698/drug-therapy/use-and-misuse-opioid-agonists-opioid-addiction

(August 2011). Buprenorphine and Buprenorphine/Naloxone Diversion, Misuse, and Illicit Use: An International Review. Current Drug Abuse Reviews. Retrieved December 2018 from from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3154701/

(November 2013). Addiction Treatment With a Dark Side. The New York Times. Retrieved December 2018 from from https://www.nytimes.com/2013/11/17/health/in-demand-in-clinics-and-on-the-street-bupe-can-be-savior-or-menace.html?_r=0

(January 2014). Meet Suboxone, the Street’s Hot New Drug. Muckgers. Retrieved December 2018 from from https://muckgers.com/meet-suboxone-the-streets-hot-new-drug-81b35f5cb632

(July 2018). Treating Opiate Addiction With Suboxone. Verywell Mind. Retrieved December 2018 from from https://www.verywellmind.com/suboxone-for-opiate-addiction-49543

(May 2018). The Importance of Integrated Care in Fighting Opioid Use Disorder. American Journal of Managed Care. Retrieved December 2018 from from https://www.ajmc.com/contributor/caroline-carney/2018/05/the-importance-of-integrated-care-in-fighting-opioid-addiction

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