What is Precipitated Withdrawal?

What is Precipitated Withdrawal
Medically Reviewed By: Dr. Joshua Yager M.D.

Medically Reviewed By: Dr. Joshua Yager M.D.

Dr. Joshua Yager is an Atlanta native, board-certified family practice physician who is dedicated to the health and wellbeing of his community.

Table of Contents

What is Precipitated Withdrawal?

Precipitated withdrawal is a condition where withdrawal symptoms are induced by the medications used in substance abuse treatment rather than by ceasing the use of the addictive substance. This phenomenon is closely linked to medication-assisted treatment (MAT) strategies, which are employed to facilitate the recovery from addiction. Key medications known to potentially initiate precipitated withdrawal include:

  • Suboxone
  • Subutex
  • Naltrexone

These medications aim to ease the recovery journey by curbing cravings and obstructing the opioid effects. Nonetheless, when these medications are given incorrectly or too shortly following the last opioid intake, they might unintentionally trigger early onset withdrawal symptoms.

How to Prevent Precipitated Withdrawal

Before embarking on a drug addiction treatment program, it’s essential to have a clear understanding and realistic expectations to circumvent the risk of precipitated withdrawal. For those who are physically dependent on opioids, it’s critical to ensure they are not currently experiencing the opioid’s active effects. A reliable approach to gauge treatment readiness is to assess for clear withdrawal symptoms, aiming for a Clinical Opioid Withdrawal Scale (COWS) score between 5 to 6 at the minimum, though scores above 10 are preferable.

The necessary period of opioid abstinence before initiating treatment can differ widely among individuals. As such, the time elapsed since the last opioid dose—regardless of whether the opioid was short-acting or long-acting—should be considered a general estimate for when withdrawal symptoms may appear. The initial phase of treatment involves a comprehensive review of the patient’s most recent opioid usage, assessment of both objective and subjective withdrawal symptoms, and the calculation of a COWS score. If the patient has not reached at least a mild to moderate withdrawal level (indicated by a COWS score of 5 to 24), delaying treatment may be the best course of action. Notably, withdrawal from long-acting opioids typically requires a longer waiting period than for short-acting opioids.

Drugs That Can Cause Precipitated Withdrawal

Precipitated withdrawal (POW) is a condition instigated by certain medications that interfere with mu-opioid receptors, which are the same receptors targeted by opioids. These medications can prevent opioids from binding to these receptors, leading to the symptoms associated with POW. The following are medications that have been identified as potential triggers for this condition:

  • Buprenorphine: Often utilized in medication-assisted therapy for opioid addiction, buprenorphine helps manage cravings following detox. Acting as a partial opioid agonist, it attaches to mu-opioid receptors but produces a reduced effect compared to full opioids. It is available under brand names such as Subutex and Suboxone.
  • Butorphanol: A pain reliever that acts as a partial opioid agonist and can induce POW.
  • Nalbuphine: Similar to butorphanol, nalbuphine offers pain relief as a partial opioid agonist and has the potential to trigger POW.
  • Naloxone (Narcan): An emergency medication for reversing opioid overdose, naloxone acts as an opioid antagonist, displacing opioids from mu receptors and may cause POW.
  • Naltrexone (Vivitrol): Used in treating both alcohol and opioid dependency, naltrexone is an opioid antagonist that could lead to POW.
  • Alvimopan (Entereg): Prescribed for specific post-operative bowel complications, alvimopan is an opioid antagonist and is not recommended for individuals recently using opioids as it may precipitate POW.
  • Naloxegol (Movantik): Aimed at addressing opioid-induced constipation (OIC) in those on long-term opioid treatment, naloxegol is an opioid antagonist that could initiate POW in people with compromised blood-brain barriers.
  • Naldemidine (Symproic): Another treatment for OIC, naldemidine is an opioid antagonist that may cause POW in individuals with blood-brain barrier issues.
  • Methylnaltrexone (Relistor): Also for OIC, methylnaltrexone is known to potentially trigger POW in individuals with abnormal blood-brain barriers.

Some drugs might also hasten the elimination of opioids from the body, which can lead to withdrawal symptoms. These drugs include:

  • Rifampin, a treatment for tuberculosis
  • Phenytoin, used for seizure control
  • St. John’s Wort, a supplement for mood enhancement
  • Phenobarbital, another seizure medication
  • Carbamazepine, also a treatment for seizures

Grasping how these medications interact with opioid usage is vital for effectively managing and avoiding precipitated withdrawal, underscoring the necessity for medical oversight during the treatment of addiction.

Precipitated Withdrawal Symptoms

Precipitated withdrawal poses a unique obstacle in heroin addiction recovery, especially due to the strong affinity certain treatments, such as buprenorphine, have for opioid receptors in the brain. When buprenorphine is given to someone with a heroin dependency, it effectively replaces heroin at the brain’s opioid receptors but with a significantly less intense opioid effect. Transitioning from a strong opioid like heroin to a milder option like buprenorphine can lead to a sudden onset of withdrawal symptoms, as the body reacts to the reduced opioid stimulation.

This sudden change can lead to a variety of uncomfortable symptoms, including:

  • Muscle aches
  • Fever
  • Abdominal cramps
  • Increased sweating
  • Difficulty sleeping
  • Pupil dilation

For those who have extensively used heroin and developed a significant physical dependence, these withdrawal symptoms can be particularly severe, including:

  • Profound depression
  • Diarrhea
  • Suicidal ideation
  • Rapid heartbeat
  • High blood pressure

Although buprenorphine is an opioid designed to ease withdrawal for those with significant opioid dependencies, it can paradoxically initiate withdrawal symptoms in individuals who have developed a high tolerance to heroin. This highlights the complexities involved in opioid addiction treatment and the importance of cautious, medically supervised administration of buprenorphine.

If you or someone you love is experiencing precipitated withdrawal in Atlanta, GA, understand that the fear of withdrawal can deter individuals from seeking necessary treatment. Our compassionate team is here to support you through this challenging time. Contact us at 678-929-6304 or visit our fill out our online webform to start your journey towards recovery from precipitated withdrawal.

How Long Does Precipitated Withdrawal Last?

The length of time precipitated withdrawal symptoms last is not one-size-fits-all and can differ greatly among individuals. Several critical factors play a role in determining the duration of these symptoms. Your medical professional can provide an individualized forecast based on various considerations, including:

  • The nature of the drug causing the withdrawal, whether it’s short-acting or long-acting
  • The amount of the drug taken
  • The specific opioid used, how much was typically taken, and the length of time it was used

Grasping these factors is crucial for anticipating the course of precipitated withdrawal. This knowledge enables both patients and caregivers to better strategize for the management and treatment of symptoms throughout the recovery journey.

How to Stop Precipitated Withdrawal 

Starting treatment for precipitated withdrawal symptoms is still feasible even after they’ve started to manifest. Healthcare providers, especially those in emergency medical environments, are prepared to address precipitated withdrawal (POW) with customized treatment plans that consider key aspects:

  • The specific opioid involved in the dependency
  • The amount of opioids the individual was taking
  • How long the individual has been using opioids
  • The particular medication that initiated the withdrawal symptoms
  • The amount of the drug that led to the withdrawal

Taking into account these factors allows medical professionals to formulate an effective approach to mitigate the discomfort of precipitated withdrawal. This ensures that patients receive the necessary care and support to navigate through the recovery phase successfully.

How to Treat Precipitated Withdrawal

Navigating through precipitated withdrawal can be challenging due to its distressing symptoms, yet the right approach can greatly ease these discomforts. Notably, buprenorphine—potentially the cause of the initial withdrawal symptoms—can be instrumental in relieving them. If you’re facing unbearable discomfort or find yourself considering opioid use to find relief, the following actions are recommended:

  • Discuss with your healthcare provider the option of getting prescribed buprenorphine.
  • Reach out to your opioid addiction treatment center to inquire about receiving buprenorphine.
  • If obtaining buprenorphine promptly through your doctor or treatment facility is not possible, visiting an emergency room can offer the immediate care needed to manage your symptoms.

To reduce the likelihood of precipitated withdrawal, ensuring a sufficient waiting period post your last opioid use before initiating buprenorphine treatment is crucial:

  • For individuals using short-acting opioids such as heroin, oxycodone, Percocet, and Vicodin, waiting at least 12 to 24 hours is advisable.
  • In the case of long-acting opioids like methadone and Oxycontin, a longer waiting period of 24 to 48 hours is recommended.

Treatment for Precipitated Withdrawal

Overcoming precipitated withdrawal might seem daunting, but at Hope Harbor Wellness, you’re not in this fight alone. We provide round-the-clock support, ensuring new patients can usually be seen within four hours. Our team understands that the apprehension surrounding withdrawal can prevent people from seeking the necessary treatment for addiction. That’s why we focus on creating a safe and comfortable environment for our patients throughout the withdrawal phase.

If you’re battling intense symptoms of precipitated withdrawal in Atlanta, GA, our experienced professionals at Hope Harbor Wellness are here to offer their support. We deliver a holistic addiction treatment program designed to help individuals successfully conquer substance dependency and start their journey towards healing. Through the use of Medication for Addiction Treatment (MAT), we guide our patients through the initial, often difficult, steps of recovery. For more details on how Hope Harbor Wellness can aid in your recovery process, please reach out to us at 678-929-6304 or visit our fill out our online contact form to get in touch online.


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