• Home
  • Store
    • Newsletter Subscriptions
    • Multimedia
    • Books
    • eBooks
    • ABPN SA Courses
    • Social Work Courses
  • CME Center
  • Multimedia
    • Podcast
    • Webinars
    • Blog
    • Psychiatry News Videos
    • Medication Guide Videos
  • Newsletters
    • General Psychiatry
    • Child Psychiatry
    • Addiction Treatment
    • Hospital Psychiatry
    • Geriatric Psychiatry
    • Psychotherapy and Social Work
  • FAQs
  • Med Fact Book App
  • Log In
  • Register
  • Welcome
  • Sign Out
  • Subscribe
Home » Effective Management of Buprenorphine-Precipitated Opioid Withdrawal
Clinical Update

Effective Management of Buprenorphine-Precipitated Opioid Withdrawal

January 1, 2025
Jaewon Lee, MD, MPH
From The Carlat Addiction Treatment Report
Issue Links: Editorial Information | PDF of Issue

Jaewon Lee, MD, MPH. PGY-2, psychiatry resident, University of Rochester Medical Center, Rochester, NY. 

Dr. Lee has no financial relationships with companies related to this material.

Getting your Trinity Audio player ready...

Buprenorphine is an effective first-line treatment of opioid use disorder (OUD), but because it is a partial opioid agonist, starting buprenorphine (a process known as induction) can lead to precipitated withdrawal in patients with residual opioid agonist in their system. Carefully following induction procedures can minimize this risk, but precipitated withdrawal is always a possibility. In this article, we’ll review buprenorphine induction procedures that minimize the risk of withdrawal and discuss how to manage withdrawal if it occurs. 

Avoiding withdrawal

The standard induction procedure involves two steps. The first step is ­to quantify opioid withdrawal symptom severity using a validated scale. In the hospital, the most commonly used scale is the Clinical Opiate Withdrawal Scale (COWS; www.tinyurl.com/427amss2 ). Patients undergoing home induction can use the Subjective Opiate Withdrawal Scale (SOWS; www.tinyurl.com/3wrb8frt). The second step is to start medication once the severity reaches a certain threshold (COWS or SOWS >8–10). This threshold indicates that the amount of residual opioid in the patient’s system is low enough that taking their first dose of buprenorphine won’t trigger additional withdrawal symptoms. 

An alternative method for starting buprenorphine, termed microinduction, involves the gradual introduction of buprenorphine in very small doses while the patient continues taking opioid agonists. Buprenorphine is titrated up to an effective dose, usually over the course of a week or two, and then the opioid agonist is stopped. The main advantage of microinduction is the very low risk of precipitated withdrawal. The downside is that the procedure is relatively slow, leaving the patient undertreated and at higher risk of overdose during the week or two that it takes to complete.

See CATR Apr/May/Jun 2024 for more on buprenorphine induction procedures.

If withdrawal occurs: Three options

Despite our best efforts, precipitated withdrawal will occur in a small subset of our patients. It is uncomfortable, sometimes intensely so, and can cause significant distress. While the research on how to treat precipitated withdrawal is sparse, there are three generally accepted approaches.

1) Symptomatic treatment

Opioid withdrawal symptoms include: 

  • Abdominal cramping
  • Anxiety
  • Diarrhea
  • Insomnia 
  • Muscle aches
  • Nausea
  • Tachycardia
  • Vomiting

SymptomaticTreatment_CATR_JanFebMar2025_v3.png

Symptomatic treatment focuses on alleviating these symptoms through a combination of medications, each chosen to relieve a particular symptom. See “Symptomatic Treatment for Precipitated Opioid Withdrawal” table for a rundown of medications that can be used to treat opioid withdrawal symptoms. The list may look familiar, as they are the same medications that are used to treat opioid withdrawal in patients who do not want medications for OUD (MOUD).

2) More buprenorphine

Giving the patient additional buprenorphine might initially appear counterintuitive, but it can ease withdrawal symptoms and make the patient feel somewhat better. The approach, akin to “ripping off the Band-Aid,” floods opioid receptors with buprenorphine, and at a high enough dose it can provide adequate agonism to relieve at least some withdrawal symptoms. Evidence for this approach is restricted to a handful of case reports, but the studies indicate that an additional 8–16 mg of buprenorphine, given once precipitated withdrawal takes place, leads to symptom relief in one to two hours (Spadaro A et al, Am J Emergency Med 2022;58;22–26). This may seem like a high dose to give all at once, especially considering that guidelines typically recommend not to exceed 8 mg of buprenorphine in the first 24 hours (Treatment Improvement Protocol 63. SAMHSA; 2019). However, recent studies have shown that doses of buprenorphine as high as 32 mg are safe and well tolerated (Herring AA et al, JAMA Netw Open 2021;4(7):e2117128). 

3) Switching to an opioid agonist

In cases where symptomatic treatment is insufficient or the patient is not amenable to taking additional buprenorphine doses, switching to opioid agonist treatment, namely methadone, can be effective. Studies have shown that buprenorphine and methadone both reduce morbidity and mortality associated with OUD (Santo T et al, JAMA Psychiatry 2021;78(9):979–993). Pivoting to methadone treatment may be a way of keeping your patient on MOUD after an unpleasant initial experience with buprenorphine.

If you decide to switch to methadone, it’s important to consider the potential for QT prolongation. Whenever possible, obtain a baseline ECG, a set of blood chemistries, and replete potassium and magnesium in patients with potassium <4.0 or magnesium <2.0, which will lower the risk of a prolonged QT progressing to torsades de pointes. If these tests aren’t immediately feasible, at the very least assess the patient’s cardiac risk factors, monitor them as closely as you can, and obtain the labs and ECG as soon as possible.

To dose: 

  • A typical first dose is 20–30 mg
  • 10 mg can be added if the patient is still in withdrawal (total of 40 mg in the first 24 hours after beginning treatment) 

Remember that methadone must be prescribed by a federally regulated opioid treatment program (OTP) beyond the initial 72 hours. If you are going to start the patient on methadone, be sure that they will have access to an OTP going forward.

Choosing between the three

Studies on treatments for buprenorphine-precipitated withdrawal are small, often lack control groups, and are frequently limited to case reports. No direct comparisons of different treatment strategies have been conducted. As a result, any of the three available options can be considered reasonable, each with its own pros and cons.

Symptomatic treatment focuses on alleviating discomfort but does not help the patient initiate MOUD. Adding more buprenorphine can relieve symptoms and expedite the induction process, but patients may be understandably hesitant to take additional doses. Switching to methadone effectively treats OUD but can complicate follow-up arrangements.

It’s also important to note that symptomatic treatment can be combined with either of the other two options—patients can still receive medications for symptom relief even if they are given additional buprenorphine or switched to methadone. 

Involve the patient in decision-making

Whenever possible, involve the patient in choosing a treatment path.

  • Explain the risks and benefits of each approach
  • Outline what each approach entails
  • Ask which one they prefer 

Because we have so few data, there really is no wrong choice.

Acknowledge patient experience

It is important to acknowledge the discomfort patients feel. Unfortunately, none of the strategies are likely to fully eliminate precipitated withdrawal symptoms once they start. But emphasize that the discomfort is temporary and that it should resolve in eight to 24 hours. After that time, patients will have started buprenorphine and can be titrated up to an effective dose with no fear of further precipitated withdrawal (Spadaro et al, 2022).

Carlat Verdict 

Precipitated withdrawal can occur when buprenorphine is given while the patient still has an opioid agonist in their system. Various strategies can be used to minimize the risk of precipitated withdrawal, but it will inevitably happen from time to time. When it does, offer symptomatically targeted treatments, give additional buprenorphine up to 16 mg at a time, or switch to methadone. Reassure the patient that the discomfort is temporary, and don’t discontinue MOUD.


Addiction Treatment
KEYWORDS addiction buprenorphine opioid use disorder substance use disorder
    Jaewon Lee, MD, MPH

    More from this author
    www.thecarlatreport.com
    Issue Date: January 1, 2025
    SUBSCRIBE NOW
    Table Of Contents
    Learning Objectives, Withdrawal, CATR, January/February/March 2025
    Effective Management of Buprenorphine-Precipitated Opioid Withdrawal
    Managing Withdrawal From Multiple Substances
    Navigating Cannabis Withdrawal
    Methamphetamine Withdrawal Treatment
    Long-Term Patient Outcomes with Buprenorphine for Opioid Use Disorder
    CME Post-Test, Withdrawal, CATR, January/February/March 2025
    DOWNLOAD NOW
    Featured Book
    • OUDFB1e_Cover_Binding.png

      Treating Opioid Use Disorder—A Fact Book (2024)

      All the tools you need to assess and treat patients struggling with opioid use disorder. 
      READ MORE
    Featured Video
    • KarXT (Cobenfy)_ The Breakthrough Antipsychotic That Could Change Everything.jpg
      General Psychiatry

      KarXT (Cobenfy): The Breakthrough Antipsychotic That Could Change Everything

      Read More
    Featured Podcast
    • shutterstock_2603816031.jpg
      General Psychiatry

      A Scam for Every Woman, Child, and Man: Part 2

      1 in 3 Americans were victims of online scams in the past year. Even when you know your patient is being scammed, it is hard to pull them out. We speak with Cathy Wilson about...
      Listen now
    Recommended
    • Join Our Writing Team

      July 18, 2024
      WriteForUs.png
    • Insights About a Rare Transmissible Form of Alzheimer's Disease

      February 9, 2024
      shutterstock_2417738561_PeopleImages.com_Yuri A.png
    • How to Fulfill the DEA's One Time, 8-Hour Training Requirement for Registered Practitioners

      May 24, 2024
      DEA_Checkbox.png
    • Join Our Writing Team

      July 18, 2024
      WriteForUs.png
    • Insights About a Rare Transmissible Form of Alzheimer's Disease

      February 9, 2024
      shutterstock_2417738561_PeopleImages.com_Yuri A.png
    • How to Fulfill the DEA's One Time, 8-Hour Training Requirement for Registered Practitioners

      May 24, 2024
      DEA_Checkbox.png
    • Join Our Writing Team

      July 18, 2024
      WriteForUs.png
    • Insights About a Rare Transmissible Form of Alzheimer's Disease

      February 9, 2024
      shutterstock_2417738561_PeopleImages.com_Yuri A.png
    • How to Fulfill the DEA's One Time, 8-Hour Training Requirement for Registered Practitioners

      May 24, 2024
      DEA_Checkbox.png

    About

    • About Us
    • CME Center
    • FAQ
    • Contact Us

    Shop Online

    • Newsletters
    • Multimedia Subscriptions
    • Books
    • eBooks
    • ABPN Self-Assessment Courses

    Newsletters

    • The Carlat Psychiatry Report
    • The Carlat Child Psychiatry Report
    • The Carlat Addiction Treatment Report
    • The Carlat Hospital Psychiatry Report
    • The Carlat Geriatric Psychiatry Report
    • The Carlat Psychotherapy Report

    Contact

    carlat@thecarlatreport.com

    866-348-9279

    PO Box 626, Newburyport MA 01950

    Follow Us

    Please see our Terms and Conditions, Privacy Policy, Subscription Agreement, Use of Cookies, and Hardware/Software Requirements to view our website.

    © 2025 Carlat Publishing, LLC and Affiliates, All Rights Reserved.