Starting buprenorphine, the medicine in Suboxone and its generics, is called induction. Done well, it relieves withdrawal and cravings within hours. Done too early, it can cause precipitated withdrawal: a sudden, severe withdrawal that makes people afraid to try again.
Why timing matters
Buprenorphine attaches to opioid receptors more strongly than heroin, fentanyl or pain pills, but activates them only partly. If those opioids are still on the receptors, buprenorphine pushes them off and replaces a strong effect with a weaker one, all at once. That is precipitated withdrawal.
The standard approach
Withdrawal signs include yawning, sweating, runny nose, goosebumps, aches, stomach upset and restlessness. Your first dose is timed by withdrawal signs, not just the clock: wait for clear, moderate withdrawal, usually at least 12 hours after short-acting pills or heroin, often 24 to 72 hours or longer after fentanyl, and longer after methadone. Because fentanyl can cause precipitated withdrawal even after a long wait, your provider may recommend a low-dose or high-dose start instead. Induction may happen in our office or at home with written instructions. Your provider uses a withdrawal score to time the first dose, then adjusts over the first few days. Patients who start at home get written instructions and know how to reach our office.
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Fentanyl changes the picture
Fentanyl lingers in body fat, so precipitated withdrawal is more common even after a long wait. Two newer approaches help:
- Low-dose start, sometimes called micro-induction: very small buprenorphine doses that overlap with ongoing opioid use, increased over about a week on a schedule your provider writes out
- High-dose start: larger first doses, supervised, to get through withdrawal faster
Both are planned with your provider; do not try either on your own.
If precipitated withdrawal happens
Call your provider right away, and do not take more of any medicine, or use other opioids, unless your provider tells you to. Treatment is adjusted to you and sometimes includes more buprenorphine under your provider's direction, plus medicines for nausea, diarrhea and aches. Call 911 or go to an emergency room for chest pain, confusion, fainting, or vomiting that keeps you from holding down fluids.
Learn more about Suboxone treatment in Charleston.
Help at Hope Addiction Medicine
Our team combines medication with counseling and behavioral therapies, in person at our West Ashley office in Charleston and by telehealth when appropriate. New patients are often able to be scheduled within a week of requesting an appointment. Request an appointment or call our office.
This article is general health information and does not replace advice from your own provider. Never start, stop or change a medication without talking with your prescriber. If someone may be overdosing, call 911 and give naloxone if you have it.
Frequently Asked Questions
Your first dose is timed by withdrawal signs, not just the clock: wait for clear, moderate withdrawal, usually at least 12 hours after short-acting pills or heroin, often 24 to 72 hours or longer after fentanyl, and longer after methadone. Because fentanyl can cause precipitated withdrawal even after a long wait, your provider may recommend a low-dose or high-dose start instead. Induction may happen in our office or at home with written instructions.
A sudden, severe withdrawal that happens when buprenorphine is taken while other opioids are still on the receptors. It pushes them off and replaces a strong effect with a weaker one all at once.
A low-dose start: very small buprenorphine doses that overlap with ongoing opioid use and increase over about a week, which lowers the risk of precipitated withdrawal, especially with fentanyl.