What Is Precipitated Withdrawal?

Precipitated withdrawal is a sudden onset of withdrawal symptoms such as fever, cramping, and sweating, brought on by medication-assisted treatment with a medications like buprenorphine or naltrexone which acts to block the effect of opiate drugs on the body.

Unlike withdrawals from substance dependencies, precipitated withdrawal is caused by the use of medication and not the deprivation of a substance.

Another key difference between precipitated withdrawal and typical withdrawal is that the latter occurs gradually while the former can occur suddenly. The sudden onset of symptoms can be a frightening experience. 

Precipitated withdrawal occurs when a person who is dependent on opiates develops sudden and severe withdrawal symptoms due to the effect of buprenorphine. Understanding how medically-assisted treatment with buprenorphine works is crucial to grasp how precipitated withdrawal can occur. 

How Medication-Assisted Treatment (MAT) Works

While MAT is usually thought of as treatment for opioid use disorder, it also includes treatment for addiction to other substances such as alcohol. Some of the most commonly used MAT medications include: 

• Naltrexone: Used to block the feelings of euphoria from alcohol use
• Methadone: Used to reduce opioid cravings   
• Buprenorphine: Used to reduce and suppress opioid cravings 
• Acamprosate: Used to prevent people in recovery from alcohol use disorder from consuming alcohol  
• Naloxone: Used to prevent opioid overdose and reverse the effects of an overdose

Symptoms of Precipitated Withdrawal 

While medication-assisted treatment has proven to be effective and life-saving for people living with substance use disorders, it’s not without its downsides. The most prevalent being precipitated withdrawal. 

In short, medication-assisted treatment with naltrexone or buprenorphine forces your body to stop depending on opiates. However, if you have are not in withdrawal or have not completely stopped using opiates, when you take naltrexone or buprenorphine your body can not adjust to this sudden deprivation, causing precipitated withdrawal symptoms. These symptoms include: 

• Trouble sleeping  
• Excessive sweating 
• Fevers 
• Nausea
• Vomiting
• Dilated pupils
• Muscle aches 
• Cramps 
• High blood pressure 
• Heart palpitations 
• Diarrhea 

Precipitated withdrawal symptoms may begin within one to two hours after the first dose of buprenorphine has been administered. It will often start to subsidize within 6 to 24 hours. 

Identifying Precipitated Withdrawal 

Symptoms of precipitated withdrawal are often similar to symptoms of typical substance withdrawal. The key difference between them is that the former comes on suddenly, brought on by the use of MAT medications. On the other hand, the latter occurs gradually when a person stops using substances they’ve grown dependent on. 

One study from Australia found that precipitated withdrawal occurred in about 9% of cases where buprenorphine is used to treat substance use disorder. When someone who is addicted to opiates wants to begin treatment with buprenorphine, one tool often used to measure withdrawal symptoms is the Clinical Opiate Withdrawal Scale (COWS). COWS provides a rating for 11 common signs of opioid withdrawal, which doctors can use to assess a person’s level of withdrawal from opioids.

If your doctor determines that you are in the midst of withdrawal from opiates and then administers an appropriate dose of buprenorphine, your symptoms will rapidly diminish. If, however, the buprenorphine is administered too soon after your last dose of opioids, before you are in withdrawal, the buprenorphine will act as an opioid antagonist and cause precipitated withdrawal.

Naltrexone can also cause precipitated withdrawal in someone dependent on opioids who still has them in their system. Once naltrexone has been started, it acts to block the effect of opioids and prevents people from getting high off of opiates. It also helps prevent overdose.

Causes of Precipitated Withdrawal 

The use of drugs which can act as opioid antagonists triggers precipitated withdrawal. Buprenorphine is a partial opioid antagonist which is used to treat opiate use disorder. It is the most common medication used in MAT plans. To understand how this opioid antagonist triggers precipitated withdrawal, you need to understand how buprenorphine works. 

Opioid antagonists work by blocking opioid receptors in your body from receiving reward signals from opioids in your system. They also prevent you from feeling the effect of opioids if you keep using them. However, for a person who has become dependent on opioids, the sudden loss of the effects that opioids produce can trigger precipitated withdrawal. Although buprenorphine is only a partial opioid agonist, it can produce similar results as opioid antagonists such as naltrexone.

The manner in which MAT medications are administered can help prevent precipitated withdrawal from occurring. This is why it’s important to use them with with the guidance of a healthcare professional. 

Treatment for Precipitated Withdrawal 

Treatment for precipitated withdrawal is tricky. Using more buprenorphine when experiencing symptoms of precipitated withdrawal can stop the symptoms. However, this is counterintuitive as precipitated withdrawal is brought on by the buprenorphine in the first place. 

• Ironically the most effective treatment for precipitated withdrawal is buprenorphine which is often responsible for triggering the condition in many cases. If you are experiencing precipitated withdrawal, your healthcare provider will most likely continue administering buprenorphine until your symptoms stop. 
• In one case study, rapidly increasing the dosage of buprenorphine in a patient who was experiencing buprenorphine-induced precipitated withdrawal was proven to be effective in treating symptoms of the phenomenon. 
• In another 2022 study of a case of buprenorphine-induced precipitated withdrawal in a person who was already in moderate opioid withdrawal, a high dose of buprenorphine-naloxone was administered. By the next day, the patient exhibited no signs of opioid withdrawal.

Coping With Precipitated Withdrawal

Precipitated withdrawal can be an incredibly uncomfortable experience lasting anytime between a couple of hours and a few days. A few tips to help you cope with the troubling symptoms include: 

• Drink a lot of water: Staying well hydrated is crucial when experiencing precipitated withdrawal. It’s common for excessive sweating, diarrhea, and vomiting to occur. All of these can cause you to become dehydrated very quickly. Understandably, doing anything, including drinking water regularly, can be difficult. You can alternate between drinking water and drinks with electrolytes and sucking on ice cubes or eating foods with high water content, such as watermelons. 
• Reduce stress: Eliminating stressors within your control can help you stay relaxed and focused on recovering from your symptoms. 
• Treat symptoms as they occur: With your healthcare provider's recommendations, you can treat symptoms as they crop up. If you have diarrhea, you can take drugs like Imodium. If you are in pain, you can take over-the-counter painkillers like paracetamol/acetaminophen.
• Get medical help: If you begin to experience precipitated withdrawal symptoms, contact your healthcare provider as soon as possible. Trying to ride it out alone can make an already challenging experience even more difficult. 

A Word From Verywell 

Buprenorphine remains a key fighter in the fight against opioid dependence and other substance use disorders despite its side effects. However, it’s important only to use buprenorphine when under medical supervision. A single dose can bring on symptoms of precipitated withdrawal. 

How MAT medications are administered determines how effective the treatment will be and prevents side effects from occurring.