Beginning Buprenorphine Treatment
Avoiding precipitated withdrawal with home induction
Summary:The goal of induction (the beginning of treatment) is to
suppress the symptoms of cravings and withdrawal as quickly as possiblewith adequate doses of buprenorphine. Under certain conditions
buprenorphine can trigger the onset of withdrawalsymptoms. This is avoidable, but if it does happen, taking
more buprenorphine eventually stops the withdrawal.1,2,3,4,5
What is precipitated withdrawal?
Your first dose of buprenorphine can actually trigger (precipitate), withdrawal symptoms in some cases. It does this by expelling and then replacing opioid molecules already attached to the opioid receptors in the brain. When buprenorphine replaces the other stronger opioids, the buprenorphine produces a much weaker opioid effect. The cumulative effect of millions of receptors being replaced with less effect-producing buprenorphine is a sudden net decrease in overall opioid effect. In some cases this decrease may extend below the minimum amount of opioid effect needed to stave off withdrawal. This is experienced by the patient as intense withdrawal symptoms from a sudden decrease of overall opioid effect. Being in mild withdrawal before starting buprenorphine prevents this sudden drastic onset.1
Advancement in Understanding
Early recommendations (without the benefit of years of clinical experience) called for a slow increase of buprenorphine with low maximum doses for the first few days. Often these minimum doses were not enough to suppress withdrawal and patients would not return for day 2 of the process, some would relapse and die. With clinical experience it was found that dosing-to-effect on day one saved lives. No longer were there maximum doses, instead the patients would receive increasing doses of buprenorphine until objective and subjective signs and symptoms of the addiction were suppressed. This meant many patients received a total of 16mgs of buprenorphine on day one, with some methadone transfers requiring 32mgs. 1,2
The patient should be in mild to moderate withdrawal before taking the first dose of buprenorphine. Don't go by some set time from last use, instead go by symptoms. There is actually a scientific way to rate symptoms with this guide - COWS. It is not necessary to be in withdrawal for very long, or be in deep withdrawal. Some physicians recommend fasting for the previous 12 hours in case you experience nausea during the induction.1
First dose of buprenorphine
If you have a very low level of physical dependence, start at 1mg. For midrange levels of physical dependence start at 2mgs, and for high levels start at 4mgs.1
Subsequent doses of buprenorphine
Thirty minutes after the first dose evaluate the symptoms using the COWS. While symptoms score above 10 take an additional 2mgs. Do this every 30 minutes until symptoms of withdrawal and cravings stop. Typically this happens around 4-16mgs, but with some methadone transfers or time release Oxycodone medications it could require much more. For others 2mgs will be all that is needed.1
Buprenorphine builds up in the blood, it will take about 10 days to stabilize. This also means the effects of dose decreases cannot be reliably evaluated until 10 days after the change.1
Fine tune buprenorphine dose
After stabilization and the risk of relapse has diminished it's a good time to fine tune the dose so you are not taking more than needed. To do this drop 2mgs (or 25% if your dose is less than or equal to 4mgs) every 10 days until withdrawal symptoms become noticeable, then go back up 2mgs (or 25%). This is your minimum effective dose.
What if you put yourself into precipitated withdrawal?
If you feel more withdrawal after taking the buprenorphine than before, then you are experiencing precipitate withdrawal. To fix it you take more buprenorphine. This might seem strange to some people because if some buprenorphine causes withdrawal won't more cause more withdrawal? No. Remember, the cause of the withdrawal is not enough opioid effect, and buprenorphine causes opioid effect, so taking more will eventually breach the threshold of withdrawal and suppress symptoms. Follow the same procedure and increase by 2mgs. every 30 minutes.
- TIP-40, buprenorphine treatment clinical guidance - government document 2004
- PCSS clinical guidance on buprenorphine induction- Buprenorphine induction - clinical experience
- Home induction of buprenorphine - study
- Anecdotal evidence compiled from several social media sites over a period of several years
- NAABT- Avoiding precipitated withdrawal published 2011