How to Start Buprenorphine-Naloxone, Precipitated Withdrawals, and More
This is for informational purposes only. Do not use any information in this blog to guide your treatment. This was originally written as a reference for our patients. You must follow the instructions of your provider.
Suboxone and Zubsolv (Buprenorphine-Naloxone). Buprenorphine is the active part of this medication.
What is Buprenorphine-Naloxone Induction? This is the process of starting Buprenorphine-Naloxone which often takes a few days. When this process is done correctly, starting Buprenorphine-Naloxone is usually straightforward and most people are able to start Buprenorphine-Naloxone without too much fuss. However, for a number of people, this can be a more difficult process. Do not give up if you have a more difficult time; there are many factors to consider as to why this may be the case for you
How do I start Buprenorphine-Naloxone? In summary, you stop taking any other opioids and allow yourself to go into opioid withdrawal. Once you are experiencing severe or close to severe opioid withdrawal symptoms start with just a tiny bit of Buprenorphine-Naloxone, like a 2-0.5 mg tab/ film or a quarter of an 8-2 mg tab/film. After an hour, if you are feeling the same or a little bit better, you can take another 2-0.5 mg. Repeat this process until you are not experiencing opioid withdrawals. Do not exceed a total of 16-4 mg in a day. The real and best version of how to start Buprenorphine-Naloxone which is the way you need to go about doing it is to follow the instructions of your prescribing provider!
Starting Buprenorphine-Naloxone
1) Stop taking all opioids for at least 12 to 36 hours before starting Buprenorphine-Naloxone. If you are not in opioid withdrawal by this time, or you were taking a long-acting opioid such as Methadone, you will have to wait longer, up to 3 days plus in some cases. More important than waiting a certain amount of time is that you are in severe or close to severe opioid withdrawal before starting where you are experiencing at least a few of the following symptoms:
Anxiety
Chills
Eyes are tearing
Goosebumps
Muscles and joints ache
Nausea
Restlessness
Runny nose
Shaking
Stomach cramps
Sweating
Yawning
2) When you are in severe or close to severe opioid withdrawal with at least a few of the listed symptoms, put 2 mg of Buprenorphine under your tongue.
This is equal to a quarter of one Buprenorphine-Naloxone 8-2 mg tab/ film (cut your Buprenorphine-Naloxone 8-2 mg tab/film into 4 equal pieces, start with one of these four pieces) or an entire Buprenorphine-Naloxone 2/0.5 mg tab/film.
Keep your mouth closed. Do not swallow the medication, chew it, or move it around in your mouth. Do not talk, drink anything, or smoke for 15 to 20 minutes. Let the medication sit under your tongue; it gets absorbed directly into your bloodstream. Any medication that is swallowed is mostly wasted medication and will not work. After 15 to 20 minutes have passed, rinse your teeth and gums with water and swallow. An hour later, brush your teeth. Also, follow up with a dentist for routine dental care (this medication is bad for your teeth).
3) Wait an hour, if you are feeling the same or a little better, take another 2 to 4 mg of Buprenorphine.
That is, take a quarter or up to a half of a Buprenorphine-Naloxone 8-2 mg film/ tab, or if you are taking Buprenorphine-Naloxone 2-0.5mg tabs/films- one or up to two of these.
4) You can keep repeating this process after waiting an hour between doses until you are feeling okay enough to stop or no longer have opioid withdrawal symptoms. Do not take more than the amount that your provider told you not to exceed in a day’s time, often but not always 16-4 mg in a day’s time (two Buprenorphine-Naloxone 8-2 tabs/ films).
5) Repeat this process for at least 2 to 3 days. Remember the amount of Buprenorphine-Naloxone you needed on each day. This is how you figure out the lowest effective dose that you need.
Your provider will explain this to you. Day to day, you will likely need anywhere from less than 2-0.5 to 16-4 mg a day of Buprenorphine-Naloxone depending on the amount of opioids you were taking before. Many people do well with less than Buprenorphine-Naloxone 16-4 mg a day, few people need more than 16-4 mg a day
Precipitated withdrawals
When you are starting this process, you will already feel lousy because you have to allow yourself to go into opioid withdrawal as described above. If after your first 2mg dose of Buprenorphine, you start to feel significantly worse, you are experiencing precipitated withdrawals, that is, the Buprenorphine-Naloxone is making you sick because you are taking it too soon. Whatever opioid you were taking before trying to start Buprenorphine-Naloxone is still attached to your opioid receptors. If you experience this, contact your provider. There are several approaches to this experience.
1) restart the process where you allow yourself to be in opioid withdrawal but wait that much longer before you reattempt starting Buprenorphine-Naloxone. The longer you wait and the worse your withdrawal symptoms are, the less likely you are to experience precipitated withdrawals. If your provider gave you medications for opioid withdrawal symptoms (often called comfort meds), you may use them as directed by your provider to help this process. I prescribe a number of these medications to my patients to help with this process.
2) Attempt something akin to micro-dosing. Instead of starting with 2mg of Buprenorphine, start with a much smaller dose or a much smaller piece of Buprenorphine-Naloxone and continue to take very small pieces.
3) Wait as long as you can. If you take Buprenorphine-Naloxone and it makes you sicker (it is causing precipitated withdrawals), continue to take a dose every hour until you feel better. Still, do not take more than 16-4 mg in a day or the amount that your provider told you not to exceed in a day. If you were given comfort meds, you may be able to use them if instructed as such by your provider
There are other more controversial approaches that you may discuss with your provider if you have ongoing difficulty starting Buprenorphine-Naloxone.
More Information & Definitions
What are opiates and opioids? We all have opioid receptors in our brain and body. Opiates and opioids are both drugs that bind to these opioid receptors and cause similar effects and have similar risks such as causing euphoria (a state of intense happiness or feeling good), drowsiness, dependence, addiction, and more. The key difference is that opiates are natural drugs that are derived from the opium poppy plant (e.g., heroin, morphine, and codeine) and opioids can be natural, created in a laboratory, or chemically altered natural opioids (e.g., oxycodone, Percocet, Norco, fentanyl, methadone, Buprenorphine, tramadol). The term opioid can be used to encompass both opiates and opioids.
What is opioid withdrawal? Opioid withdrawal is a set of symptoms that are experienced when a person who is dependent on opiates or opioids stops taking them. These symptoms may include but are not limited to temperature dysregulation with feeling hot and cold, chills, anxiety, watery eyes, goosebumps, body aches, nausea, restlessness, runny nose, shaking, stomach cramps, sweating, yawning, irritability, diarrhea, difficulty sleeping, and a fast heartbeat. A person becomes dependent on opiates and opioids after taking them for a significant amount of time which varies from person to person.
Buprenorphine-Naloxone Induction. Buprenorphine-Naloxone induction is the process of starting Buprenorphine-Naloxone. It is the process of stopping an opiate or opioid such as Heroin, Fentanyl, Methadone, or any number of opioid pain pills and starting Buprenorphine-Naloxone. A concern is that when you stop an opioid, you get sick, that is, you experience opioid withdrawal; and, if you take Buprenorphine-Naloxone right after stopping an opioid such as those listed, that is, if you take Buprenorphine-Naloxone too soon, it will make you sick which is what we refer to as precipitated withdrawals.
Buprenorphine-Naloxone. For your information, Buprenorphine-Naloxone is a controlled substance. Buprenorphine-Naloxone is an opioid that causes physical dependence in the same way that other opiates and opioids cause physical dependence. With that, if you start taking Buprenorphine-Naloxone and then you stop taking it, due to physical dependence, you will get sick (have opioid withdrawals) the same way any person who stops taking any opiate or opioid would. Some reports state that physical dependence can happen in a few days while others report a couple of weeks.
Start Buprenorphine-Naloxone treatment with a doctor
If you have questions or want to start treatment with Buprenorphine-Naloxone (or the Buprenorphine injection) call 219-850-4490 or schedule an appointment online.
This is for informational purposes only. Do not use any information in this blog to guide your treatment. This was originally written as a reference for our patients. You must follow the instructions of your provider.
