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Starting treatment for opioid use disorder (OUD) is a big step toward recovery. Switching from opioids to buprenorphine/naloxone (sold under the brands Suboxone and Zubsolv) can feel like a scary transition.
Buprenorphine/naloxone is used as part of a medication-assisted treatment (MAT) plan to help people stop taking opioids.
Many people are nervous to start these medications because they’re associated with precipitated withdrawal, an intense period of severe opioid withdrawal. But there are ways to lower the risk of developing these symptoms.
This article will focus on how and when to start buprenorphine/naloxone safely and effectively.
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When starting buprenorphine, timing is key to preventing precipitated withdrawal. Understanding how the medication works helps explain why.
Buprenorphine is a partial opioid agonist that dissolves under the tongue when taken orally. This medication attaches tightly to the brain’s opioid receptors, so other opioids can’t attach as easily. It even displaces opioids (like heroin, oxycodone, and fentanyl) that may already be attached to the receptors. Once attached, it partially activates the receptors — causing opioid-like reactions, but much weaker.
This can shock your system if it’s not done carefully. Buprenorphine replaces full-strength opioids on millions of receptors with weaker reactions. The brain suddenly doesn’t receive the stimulation it’s used to, which can cause precipitated withdrawal.
A common treatment for OUD combines buprenorphine and naloxone in one medication, such as Suboxone. Buprenorphine helps reduce opioid cravings and withdrawal symptoms. Naloxone is added to discourage misuse of the medication.
When taken as prescribed, very little naloxone enters the bloodstream, so it has little effect. However, if someone injects the medication instead, naloxone can block opioid effects and may cause sudden, uncomfortable withdrawal symptoms in people who are physically dependent on opioids.
Timing your first dose of buprenorphine (and taking it properly) can help prevent severe withdrawal symptoms.
Doctors recommend waiting until you have entered early opioid withdrawal, or when your brain is already receiving fewer opioids. Opioid withdrawal isn’t usually as severe as precipitated withdrawal, but it can still be uncomfortable.
The timing depends on the type of opioid you’ve been using. After your last dose, it may take hours or days for opioid withdrawal symptoms to begin.
Below are general timeframes for how long someone may need to wait after their last opioid dose before starting buprenorphine/naloxone:
Since the timing can vary, it’s important to talk to your doctor to find out when you should start buprenorphine/naloxone.
Heroin is a short-acting opioid. Heroin-related opioid withdrawal symptoms are expected to appear within six to 12 hours, so doctors often recommend waiting 12 hours to take buprenorphine/naloxone.
The correct time for you to begin will depend on your symptoms and the formulation of opioid you’ve been taking.
Remember to always consult a healthcare professional before starting treatment to receive medication instructions specific to your needs, which can help prevent precipitated withdrawal or serious complications.
Induction therapy, or starting your first dose of treatment, is a commitment to recovery. You may be ready to start when you feel motivated to make the change and hopeful about your recovery plan, even if you’re nervous about your journey.
One MyOpioidRecoveryTeam member shared their thoughts on starting treatment: “When I started treatment recently, I had to ask myself important questions, like why I want to be off opioids and what’s changed in my life, to see what’s motivating me. I had to be realistic — but when you’re ready, you go for it.”
Mixed feelings are normal, but knowing what to expect helps you mentally prepare for what’s to come.
Once you’re ready to start treatment, discuss your plan with a healthcare provider. They may schedule an appointment where you’ll have lab tests done and learn important information about your care plan. You’ll also learn when you should start treatment based on the opioids you’ve been taking.
Your care team may offer the option to start at the doctor’s office or at home. Taking your first dose under your care team’s watch may offer more support, but taking it at home might be more comfortable.
You’ll discuss the best option with your doctor, but supervision is often safest, especially if you’re worried about precipitated withdrawal.
You should be starting to feel mild withdrawal symptoms from stopping your opioid before starting your induction dose. Pay close attention to these symptoms, as they help guide your treatment.
They may include:
Based on your care team’s evaluation, your doctor will recommend a maximum induction dose for your first day. You won’t take the entire dose to start. Instead, you start at a low dose, then add more doses if necessary until you reach your maximum induction dose.
During this process, you and your clinician watch your withdrawal symptoms. If you continue to have withdrawal symptoms, they may continue adding to your first day’s dosage up to the maximum induction dose prescribed. If you feel better, you’ll stop for the day.
Your care team uses the first day’s dose to determine the second day’s dose, though your doctor may have specific instructions for your case.
If you feel some withdrawal symptoms, your care team may start you with a slightly higher dose. And if you develop more symptoms later in the day, they may add another dose.
As days go on, your care team will guide you on what dosages are most appropriate based on your withdrawal symptoms. You’ll check in with your care team regularly, often once per week for the first month.
To avoid side effects or complications, don’t change the dosage or stop therapy without discussing it with your doctor. Talk to your doctor about taking other medications for overlapping health problems to make sure they don’t interact with your current treatment.
Even though clinical guidance during MAT helps prevent precipitated withdrawal, symptoms are still possible.
Doctors don’t currently agree on what counts as precipitated withdrawal. But generally, symptoms develop fast — within one hour of your first dose — and feel like more intense versions of opioid withdrawal.
Based on the Clinical Opiate Withdrawal Scale, more intense withdrawal symptoms might include:
These symptoms can ease within six to 24 hours, but they can last longer, especially if you previously used long-acting opioids.
If you’re in the clinic, tell your doctor if you’re noticing a strong wave of symptoms. They may offer medications, like clonidine, that can be safe to take with buprenorphine and can reduce anxiety, agitation, sweating, and muscle aches. If you’re at home, call your doctor right away and ask what to do next.
Deciding to stop taking opioids isn’t easy, but support is available. If you’re not sure where to turn, talk to an addiction specialist at a clinic about next steps in your recovery. Many have opioid treatment programs designed to guide you through this process safely and with as few complications as possible.
Counseling can also help you build healthy coping skills. A counselor can support you throughout your journey and help you overcome mental obstacles.
Taking other opioid medications, drinking alcohol, or taking sedatives during OUD treatment can have serious side effects. Call for help immediately if you’ve mixed substances, and keep an emergency supply of naloxone on hand to help manage an accidental overdose.
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