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Suboxone Withdrawal & Detox Guide

Medically Reviewed By: Benjamin Caleb Williams RN, BA, CEN

Written By: Phillippe Greenough

Article Updated: 09/24/2020

Number of References: 8 Sources

Suboxone is commonly prescribed to aid in opioid addiction treatment, but this does not mean it is without risk. Suboxone withdrawal, while not directly dangerous, is uncomfortable and may last much longer than withdrawal from the drug addiction it is meant to treat. The Suboxone withdrawal syndrome is very similar to opioid withdrawal, although less intense, and will require treatment if someone wants the best possible chances of overcoming it. Here we will dive into Suboxone withdrawal symptoms, the timeline involved, as well as the specific effects that Suboxone withdrawal produces.

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Symptoms of Suboxone Withdrawal

Suboxone withdrawal symptoms are definitely unpleasant and quite long-lived. While not as intense as withdrawal from many other opioids, the symptoms are very similar in nature and often last for about a month. These symptoms may initially be very mild but will increase over several days before reaching their peak. Even though the physical symptoms are minimal, the psychological symptoms can be intense and the long duration of symptoms can often lead to relapse unless someone seeks treatment. It is highly recommended to enter a Suboxone detox center when expecting to go through Suboxone withdrawal.

To better understand the experience of Suboxone withdrawal, it will be helpful to get a clear picture of the way this drug works. Suboxone is a combination of two different medications, buprenorphine and naloxone. When Suboxone is taken orally the main active ingredient is buprenorphine. Naloxone is an adjunct that is intended to reduce the potential for IV use, as it neutralizes any opioids when it is injected, although when taken orally this effect is negligible since it is not effectively absorbed orally. Buprenorphine is a partial opioid agonist, which means it works on the opioid system of the brain. While it does have a high affinity for opioid receptors and a long duration of action, it does not activate these receptors as strongly as other opioid drugs will. This has the effect of reducing opioid withdrawal symptoms for a long time while not producing the high or euphoria that using other opioid drugs produces.

Even though Suboxone does not produce a strong high or euphoria, someone using it for extended periods can still experience Suboxone withdrawal since it will still produce tolerance and finally dependence, up to a point. In the case of Suboxone, it exerts its effects by stimulating the μ (Mu) and δ (Delta) opioid receptors. Through chronic stimulation of these opioid receptors, the brain will begin to reduce the sensitivity of these receptors through a process known as downregulation. This is the brain’s attempt to maintain efficient function and maintain neurotransmitter balance. Additionally, the brain may reduce “endogenous” or natural opioid peptide production if there are consistently increased levels of “exogenous” or externally introduced opioid drugs, such as Suboxone.

This has the effect of opioid receptors in the brain requiring more stimulation to become activated, as well as the brain having less natural opioid neurotransmitters to activate these receptors. The opioid system in the brain is used for a variety of tasks including pain management, reward and motivation, and emotional regulation. There are also a large number of μ-opioid receptors in the intestines and gut, so opioids also affect digestive function in the body. Due to downregulation at these opioid receptors, all of these systems are thrown out of balance and the body and mind experience a chaotic period which is known as Suboxone withdrawal.

Suboxone withdrawal may be divided into 2 distinct phases: acute withdrawal and post-acute withdrawal. These phases exhibit different symptom intensity and will resolve over very different timelines. Due to Suboxone’s long duration of action (24-36 hours) withdrawal symptoms will begin very slowly and take an exceptionally long time to reach their maximum. While the physical symptoms will resolve first, the psychological symptoms will be the longest-lasting by far.

Acute Suboxone Withdrawal

The acute phase of Suboxone withdrawal is the first and most physically intense phase. While quite long-lived as far as acute withdrawal syndromes are concerned, this time is characterized by physical symptoms as well as the intensification of the psychological symptoms. Within a few days of the last time Suboxone was used, the physical symptoms will begin to appear.

Some of the most commonly reported symptoms of acute Suboxone withdrawal include:

  • Fever and Chills (feelings of simultaneous hot and cold)
  • Diaphoresis (excessive sweating)
  • Fatigue and Lethargy
  • Insomnia
  • Reduced or Absent Appetite
  • Diarrhea and Stomach Cramps
  • Muscle Pain
  • Minor Shakes or Tremors
  • Tachycardia (elevated heart rate; usually minor)
  • Increasing Anxiety
  • Worsening Depression
  • Severe Irritability and Restlessness
  • Repeated Yawning
  • Rhinorrhea (an extremely runny nose)

This phase is extremely uncomfortable in a physical sense, with the psychological discomfort increasing as the physical symptoms begin to resolve. While only lasting about a week, this is by no means an easy week to endure. The physical symptoms will make sleep difficult and the worsening psychological symptoms can make time seem to stretch, with a minute lasting an hour, and an hour lasting a day. Medications may be used to minimize these symptoms, but the untreated experience is an absolute nightmare.

Post-Acute Suboxone Withdrawal

The post-acute phase of Suboxone withdrawal is less physically intense but is a psychologically difficult time. Characterized by primarily psychological symptoms, it may seem as if all the color, hope, and light have been drained from the world. This can be a long-lasting experience as well, commonly lasting for many months with the most intense time being immediately after the physical symptoms have resolved.

Some of the most commonly experienced symptoms of post-acute Suboxone withdrawal include:

  • Cravings for Suboxone or Opioids
  • Intense Anxiety
  • Deep Depression
  • Irritability and Restlessness
  • Difficulty Concentrating or Focusing
  • Insomnia
  • Lethargy

Depression and anxiety can dominate someone’s days, while cravings for Suboxone are prevalent. Insomnia can make the entire experience worse as it erodes someone’s mental functions and worsens irritability and lethargy. Again, medications may be used to moderate these symptoms, and treatment is highly recommended. The post-acute phase of Suboxone withdrawal is when the risk of relapse is greatest, and having support and care during this time is critical.

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Suboxone Withdrawal Timeline

The timeline for Suboxone withdrawal can vary somewhat between individuals, but there is a general trend that holds true for a majority of people. While the symptoms of Suboxone withdrawal are very similar to illicit opioid withdrawal, the timeline is greatly extended. The acute phase of Suboxone withdrawal is fairly brief (2-3 weeks), post-acute withdrawal can be a protracted experience frequently lasting for many months although the intensity decreases over time. Due to the long action of Suboxone, it can take some days for withdrawal proper to begin.

The average half-life of buprenorphine, the active ingredient in Suboxone, is around 38 hours. This means that in people with healthy liver function, half of the drug will be metabolized and cleared from their system in roughly 38 hours from the time of ingestion. Depending on someone’s level of dependence, they may begin experiencing withdrawal symptoms before or after this time to varying degrees. Once Suboxone withdrawal symptoms begin in earnest, there is a fairly standard progression and timeline.

First Week

The first week is the beginning of the acute phase of Suboxone withdrawal and while the symptoms may start out as very mild, they will gradually escalate. Symptoms should begin to appear roughly 30 to 50 hours after the last time someone used Suboxone. The first symptom to appear is commonly sweating, usually light at first and progressing to the point of constant, heavy sweating regardless of temperature. Within the first 48 hours of the onset of withdrawal, anxiety will begin to increase as well as the beginning of stomach issues such as diarrhea and cramps. The next symptom is a feeling of simultaneous hot and cold, typically described as someone feeling very hot inside with their skin feeling cold. This can cause goosebumps and chills all over. Insomnia will come to rule the night with constant restlessness resulting in frequent tossing and turning. Yawning will be frequent as well, sometimes occurring several times a minute for hours on end. Appetite will disappear by the end of the first week and muscle pains may begin at this time as well. Someone’s energy levels will plummet, leaving them totally drained and unmotivated while depression steadily increases over the first week.

Second Week

The physical symptoms will worsen throughout the course of the second week. Insomnia will still be present as well as increased restlessness and sweating. The psychological symptoms such as anxiety and depression will continue to intensify throughout the second week. Trouble concentrating may become more apparent during this time as their psychological stability begins to deteriorate due to the prolonged symptoms. This is commonly described as clouded and disorganized thinking with confusion. Additionally, cravings for Suboxone may begin to intensify around this time as well. The deepening depression and intensifying anxiety may make the thought of Suboxone more appealing, and this interplay can be very dangerous for someone’s chances of recovery.

Third Week

By the middle of the third week, sleep may still be difficult but is usually much easier by the end of the week. The depression and cravings will usually intensify during week three, while anxiety may remain high but steady throughout this week. Appetite may begin to regain normal levels around the end of the third week, and eating more will help reduce some of the discomforts. By the end of week three, the fatigue and lethargy may begin to lift somewhat, although they will still be present to some degree.

Fourth Week and Onwards

Usually, by the fourth week, the physical symptoms have drastically improved. After their peak intensity, the physical symptoms typically resolve much faster than it took them to appear and intensify. This marks a departure from the acute phase and into the post-acute phase of Suboxone withdrawal. Anxiety and depression usually reduce a bit over the course of week four, although cravings may remain unchanged for many months more. While depression and anxiety have reduced, they should also be expected to persist in some form for many more weeks although they will usually lessen in intensity as the weeks pass.

The Importance Of Suboxone Detox

Suboxone withdrawal is a very unpleasant experience, and while rarely fatal, it can be too big an obstacle for someone to overcome on their own. The medical professionals including doctors, nurses, and psychiatrists at Suboxone detox centers can help minimize both the risks and symptoms, giving someone the best possible chance to make it through this difficult process. Furthermore, these centers can provide a wealth of resources for continuing care and treatment after detox and into life after Suboxone addiction.

Suboxone Detox Center Guide

Physical Effects of Suboxone Withdrawal

While not directly life-threatening or dangerous, the physical symptoms of Suboxone withdrawal are quite uncomfortable. These symptoms may be managed with medications to reduce the severity of this discomfort, but some level of disruption to physical processes should be expected. The greatest effect is typically with the digestive and cardiovascular systems. Some of these symptoms include:

-Gastrointestinal Effects

One of the strongest effects of Suboxone withdrawal is on the gastrointestinal system. There is a large number of μ-opioid receptors in the gut and intestines, and due to Suboxone’s interaction with these receptors, the digestive system is heavily disrupted during withdrawal. These opioid receptors help to moderate intestinal muscle contractions and contribute to healthy and effective digestion.

Due to the downregulation produced through Suboxone abuse and the subsequent withdrawal syndrome, these receptors are activated more infrequently and less intensely so that they are unable to slow down these muscle contractions as they normally would. This can result in diarrhea and stomach cramping and is one of the most common symptoms of Suboxone withdrawal.

-Cardiovascular Effects

Another physical effect of Suboxone withdrawal, although more minor than digestive issues, is the effect on cardiovascular function. This is produced through a variety of factors both physical and psychological. The increased stresses of Suboxone withdrawal including anxiety and the other physical discomforts can increase levels of cortisol and other stress hormones. This can subsequently increase heart rate and even blood pressure.

The most direct contributor is most likely reduced levels of adrenaline during Suboxone use. The brain will respond to this by increasing sensitivity to adrenaline and adrenaline promoters through a process called upregulation. The end result is that once Suboxone use is discontinued, the increased sensitivity to adrenaline will produce an increased heart rate and higher blood pressure. While normally not dangerous, this can increase risks for those who may have preexisting heart or blood pressure conditions.

-Peripheral Effects

These symptoms do not necessarily fit into any one category or body system, but all are physical symptoms that result from neurological imbalances due to Suboxone withdrawal. Due to the increased adrenaline sensitivity as well as disruptions in other parts of the endocrine system, a variety of systems may be affected. Some of the direct results of increased adrenaline sensitivity include:

  • Dilated Pupils
  • Insomnia
  • Tremors or Shaking

Some symptoms which are due to general endocrine or exocrine system disruptions include:

  • Temperature Regulation Problems
  • Excessive Sweating
  • Blood Sugar Fluctuations
  • Runny Nose or Excessive Tears

An issue which has no clear cause, but which is nonetheless very common is:

  • Repeated Yawning

Psychological Effects of Suboxone Withdrawal

The physical effects of Suboxone withdrawal are certainly uncomfortable, but the psychological symptoms are by far the most severe. Not only will these symptoms ramp up in intensity over the course of weeks, but they may remain at a high level for many weeks or months. The psychological symptoms are the greatest contributor to relapse as it may feel like they will never improve. While it may feel hopeless, they absolutely will improve with time. Medications may be needed to minimize the mental discomfort and to help someone make it through the first few months of Suboxone abstinence.

-Increased Anxiety

Anxiety is often the most severe of the psychological symptoms which result from Suboxone withdrawal. Any depressant drug may produce anxiety when use ceases, and with opioids, this is especially true. Aside from producing an analgesic (painkilling) effect, opioids are general central nervous system depressants. Once the brain has adapted to their influence, the sudden removal of opioids causes a state of hyperactivity. This often manifests as an array of psychological symptoms including severe anxiety in general, and social anxiety in particular. This may take many months or even years to fully subside. Continued abstinence is the only way for this particular symptom to fully resolve.

-Depression

While anxiety may dominate the first month or so of Suboxone withdrawal, depression will eventually emerge and intensify. This is mainly due to changes in the limbic system, or “reward center” of the brain. It is known that opioids have a profound effect on the structure and behavior of this system and disruption here may result in a profound and long-lasting state of depression. The limbic system is responsible for the feelings of reward, motivation, and behavior reinforcement among many other things. Additionally, suddenly losing such a powerful, yet unhealthy, coping mechanism as Suboxone can leave someone feeling empty and contribute to the depressive symptoms that arise directly from withdrawal.

The hyperstimulation of opioid receptors produced through Suboxone use will result in an increase in the pleasure or reward threshold. This means that the required stimulus to produce these positive feelings will increase due to chronic Suboxone use. The result is that during withdrawal, any positive feelings of pleasure, reward, and especially motivation will be almost entirely absent until the brain can begin to reverse these Suboxone induced changes. This depression will resolve as the brain regains balance, but this is a very slow process. It is not uncommon for depression to persist, to some degree, for many months or years after Suboxone use has ceased. Medications are often necessary to help someone achieve a sense of normalcy while this neurological healing process takes place.

-Cravings For Suboxone

Cravings are extremely common during Suboxone withdrawal, especially in the early stages. These cravings are also a result of disruption to the limbic system, and the reinforcement of Suboxone induced pleasure. Due to the hyperarousal of the limbic system due to Suboxone use, the brain will begin to associate any positive feelings with Suboxone use.

During withdrawal, especially in the first few weeks, the intense discomfort that someone experiences will cause them to yearn for relief, understandably so. The deep connections between “feeling ok” and Suboxone will lead someone, usually unconsciously, to feel that the only relief from this state lies in Suboxone use. While doing more Suboxone will produce short term relief from the withdrawal symptoms, their situation will worsen with continued use. The only way forward is straight through; through the cravings, the depression, and the anxiety. Medications may be used to reduce the cravings, but time and abstinence is the only lasting solution.

What Factors Influence The Intensity of Suboxone Withdrawal?

The intensity of Suboxone withdrawal symptoms depends on several different factors. Both the intensity and duration of these withdrawal symptoms can be reduced or amplified by different variables. Some of these variables are choices that a user makes, while some are beyond their control. Some Suboxone users will make a full and complete recovery very quickly with light symptoms while others may go through a protracted and intense withdrawal experience.

Some of the largest contributing factors to the intensity and duration of Suboxone withdrawal include:

  • A genetic predisposition for addictive behavior
  • The amount of Suboxone someone used regularly
  • The length of time that someone used Suboxone
  • Co-occurring mental health issues

Genetics plays a large role in not only someone’s potential for addictive behavior but also how quickly they may become psychologically dependent on a substance. The exact way this works is unclear, but it may have to do with neuroplasticity. For example, the more flexible someone’s neurology is, the easier it is to adapt to the presence of Suboxone. This could speed up the process of becoming dependent as well as increase the degree of downregulation which occurs. A higher degree of downregulation produces more intense withdrawal symptoms once the drug is removed. That being said, the major contribution that genetics makes is more likely with the chances of long term recovery as opposed to the immediate symptoms experienced during detox.

The amount of Suboxone used as well as the length of time someone used Suboxone is probably the largest contributing factor to the intensity and duration of Suboxone withdrawal. These are also the variables which are completely optional; someone can choose to use more Suboxone, and use it for longer. Regardless of someone’s genetic predisposition for addiction, consistent use of large amounts of Suboxone will absolutely produce more intense and longer-lasting withdrawal symptoms, but only up to a point. The ceiling effect of euphoria displayed by Suboxone also sets an upper limit to the total severity of withdrawal symptoms as well. The more someone uses, the larger degree of opioid receptor downregulation occurs. Likewise, the longer someone uses Suboxone the more complete the downregulation process becomes, thus the longer it takes to fully reverse. Again, due to the ceiling effect, this is only true up to a certain point.

The presence of co-occurring mental health issues will contribute to the intensity and possibly duration of withdrawal symptoms, albeit in an indirect manner. If someone were to have a pre-existing anxiety disorder, then the withdrawal-induced anxiety would certainly be more intense. The same goes for depression, as someone already struggling with depression will experience worse depressive symptoms which may persist for a longer time. Additionally, a mood disorder such as bipolar disorder would be greatly amplified during the Suboxone withdrawal experience. The expected psychological symptoms of Suboxone withdrawal can amplify or compound any pre-existing mental health issues, and great care should be taken to minimize these risks through medications and supervision.

Suboxone Withdrawal Treatment

Entering a professional Suboxone treatment center will provide someone with the best possible chances of recovering from Suboxone addiction. While there are several different types of treatment centers, finding a Suboxone detox program is the recommended first step toward Suboxone addiction treatment. These detox centers specialize in treating the physical and psychological symptoms of Suboxone withdrawal and can refer patients to further treatment programs after detox is completed.

There are a variety of treatment modalities that have been very effective at treating Suboxone withdrawal. This includes medications, therapies, support services, and most importantly, medical monitoring. While Suboxone withdrawal is not directly life-threatening, a wide range of pre-existing health conditions may greatly increase the risks associated with Suboxone withdrawal. Having medical professionals on hand is crucial to the safety and success of withdrawal from Suboxone.

Medications

While there are currently no FDA approved medications for the treatment of Suboxone withdrawal, there are multiple options that have been found effective. There is a wide range of medications that may reduce the individual symptoms of Suboxone withdrawal, both physical and psychological. These may be helpful during acute and post-acute Suboxone withdrawal and may be needed for a year or more after acute withdrawal has resolved.

Some of the most commonly used classes of medication for Suboxone withdrawal treatment include:

  • Non-Narcotic Sleep Aids
  • Anti-Anxiety Medications
  • Antidepressants
  • Antidiarrheals
  • Certain Antihistamines (for anti-anxiety effects)
  • Certain Blood Pressure Medications (also for anti-anxiety effects)

These are just the general classes of medications that are commonly used. Some may be broadly applicable such as antidiarrheals and sleep aids. Other classes are more nuanced, such as antidepressants and anti-anxiety medications. Different people find different medications more tolerable and effective, so finding the most effective one is commonly done on a case by case basis. That being said, there are older medications that have proven to be widely effective which may act as a starting point.

Therapies

Aside from medications, therapeutic techniques have been extremely effective at treating the behavioral and emotional symptoms of Suboxone withdrawal. These can take many different forms, and certain individuals find some therapies more effective than others. Each person’s specific experiences and histories may dictate which therapies will be most applicable to them.

Some commonly used and very effective therapeutic techniques for treating Suboxone withdrawal include:

  • Group Therapy and Individual Counseling
  • Behavioral Therapies
  • Nutritional Classes
  • Fitness or Adventure Therapy
  • Addiction Education and Coping Skills Development
  • Aftercare Planning and Support Groups

This is just a small sample of the types of therapies that are most commonly used for treating Suboxone withdrawal. There are many more that may differ between Suboxone withdrawal treatment centers. Some therapies may be more or less effective depending on the individual, and someone will need to see what will work best for them. The guidance of the counselors, therapists, and medical professionals who work at these centers should be utilized to find the best set of treatment options.

The first step in Suboxone withdrawal treatment should be to consult a doctor and if appropriate, enter a Suboxone detox center. These detox centers will be equipped with the most effective medications, therapies, and support services to address and treat Suboxone withdrawal. These programs may give someone a wealth of resources to begin the journey of recovery from Suboxone addiction. Help is available, but someone must be willing to reach out their hand and ask.

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