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As the ongoing opioid crisis continues to spread and intensify, more people have started using naloxone and buprenorphine, some potential antidotes to reverse opioid overdoses and addictions. Previously available as a minimally-used medication only available in hospitals and ambulances is now widely available in most pharmacies and in the backpacks and purses of laypeople. However, most people do not understand that these medications, especially naloxone, can lead to a sudden, frightening, and highly painful experience called a precipitated withdrawal.
A precipitated withdrawal is a lesser-known term that many people do not fully understand. The condition is a type of withdrawal triggered by using medication instead of abstaining from it. It mostly occurs when a person uses naloxone to reverse an opioid overdose; however, recent reports have been confirming its occurrence with other drugs, such as buprenorphine and naltrexone. If you or a loved one has been relying on any of these medications, familiarize yourself with the concept of precipitated withdrawal and learn how to identify and manage it.
What is Precipitated Withdrawal, and What Causes it?
In simplest words, a precipitated withdrawal describes a condition where medications used in medication-assisted treatment (MAT) for substance use disorder management trigger withdrawal symptoms. Such withdrawal occurs due to the use of certain medication in contrast to the standard withdrawal process triggered by abstinence or absence from a chosen drug of abuse. Following are some medications commonly used in MATs with the potential to cause a precipitated withdrawal:
- Suboxone
- Subutex
- Naltrexone
To understand how a precipitated withdrawal occurs, it is imperative to understand the mechanism of how an opioid affects the brain and how MAT counter interacts with it. Opioids, such as heroin, are highly effective as they bind and activate certain opioid receptors present in the brain. These receptors contain specialized protein molecules and are present on the surfaces of brain cells. As opioid drugs latch on to these receptors, they essentially change how a cell works. The medication exerts its strong painkilling effect through these receptors, euphoria, and ultimately dependence and addiction. Opioids, such as heroin, codeine, morphine, and methadone, are full opioid agonists, which means they can fully activate the mu receptors, leading to a full spectrum of effects.
On the other hand, there are many opioid antagonists, such as naltrexone and naloxone, which work in the opposite direction of an opioid agonist like morphine. Inside the brain, these opioid antagonists compete with heroin and other similar drugs to bind with the opioid receptors. However, they do not unlock or activate them once they bind with them. In simpler words, drugs like naltrexone and naloxone aim to occupy as many opioid receptors as possible to block or stop them from activating an opioid drug. These blocking effects may last for several minutes to hours.
Sometimes, experts may use a third type of substance as a part of the medication-assisted treatment sessions, called partial opioid agonists. This drug category includes medicines like buprenorphine which also bind to the same receptors as heroin and naloxone but partially affect it. In other words, it partially activates the opioid receptors, leading to euphoria and analgesia, but with lesser intensity than the effects felt after using heroin or codeine. Moreover, the effects of buprenorphine are capped and reach a ceiling even if a person keeps increasing its dose. This effect lowers the risk of abusing this substance, making it an ideal choice to get over addictions to opioids or other full opioid agonists. However, things may go sideways even with partial agonists and full antagonists, leading to a precipitated withdrawal.
Common Precipitated Withdrawal Symptoms
To understand how withdrawal symptoms occur, consider an example of a person taking heroin who switches to buprenorphine to overcome their opioid use disorder. Buprenorphine has a strong receptor-binding affinity, and in a person already addicted to heroin, it removes and replaces the drug already attached to opioid receptors in the brain. However, because of its partial affinity, the opioid reaction it produces is significantly lesser than that of heroin. This replacement of full agonism with partial agonism can trigger a set of withdrawal symptoms in people. These effects can be highly unpleasant and may include the following:
- Muscle aches and pains
- Cramping
- Fever
- Sweating
- Dilated pupils
- Insomnia
In people who have been abusing opioids for a long time, the symptoms may become severe and may include the following:
- Depression
- High blood pressure
- Rapid heartbeat
- Suicidal thoughts
- Diarrhea
In people whose bodies have built a high tolerance level to opioids like heroin, buprenorphine can serve as a good alternative. However, it still carries the capacity to cause withdrawal symptoms.
Precipitated Withdrawal Treatment
The simplest and the most direct way to halt a precipitated withdrawal is by consuming an opioid which may feel absurd, especially when a person is trying to stop their opioid use. If a person decides to consume an opioid to stop the underlying precipitated withdrawal, it is imperative to wait until it leaves the system before they can start reusing an opioid antagonist or partial agonist, such as naloxone or buprenorphine. For people who do not wish to retake an opioid to relieve the withdrawal symptoms, other options may be available.
People having access to a prescriber or a physician may ask for a small dose of buprenorphine to control symptoms. Amazingly, buprenorphine is one of the causes of precipitated withdrawal, but its careful use can also ward off the symptoms. A person who switches from a full opioid agonist, such as heroin, to a partial agonist, such as buprenorphine, can trigger symptoms. However, the same partial agonist can relieve these symptoms during an ongoing withdrawal. In such circumstances, buprenorphine works by partially activating the opioid receptors just enough to ease the symptoms without putting the user at risk of an overdose.
Many people may hesitate before taking a dose of buprenorphine for the treatment of a precipitated withdrawal, especially if it led to its onset in the first place. However, experts agree that it can be one of the best options to get relief without involving full opioid agonists. However, this option may not always be feasible; a prescriber must have completed an “x waiver” to prescribe this medication. Other experts may simply hesitate because of the stigma surrounding opioid use disorder. Most doctors also encourage people undergoing an active precipitated withdrawal to go to the nearest emergency room for help and monitoring until they start feeling better. While the withdrawal experience can also be taken care of on your own, it is best to seek medical help to ensure safety and speed up the process.
Precipitated Withdrawal Help: How to Get Rid of Precipitated Withdrawal at Home?
There are many measures that a person can follow at home to ease the lingering symptoms of an ongoing precipitated withdrawal. These symptoms include the following:
Ask others for medication
If a prescriber does not give you naloxone or buprenorphine, ask them about any other medications that may help ease the symptoms. They may give you an alternative that helps with anxiety, restlessness, nausea, and other symptoms.
Consider over-the-counter medications
Many over-the-counter medications are available to counteract the common precipitated withdrawal symptoms. For instance, consider taking loperamide or Immodium for diarrhea, and non-steroidal anti-inflammatory drugs, such as ibuprofen, for aches and pains. Ensure you take them as prescribed and do not exceed the recommended dosage.
Stay hydrated
Maintaining hydration is a top priority while undergoing an active precipitated withdrawal, especially in people with ongoing diarrhea or vomiting. Constantly sip on water or sports drink and snack on foods with high water density, such as melon, peaches, pineapples, and cucumbers. If the withdrawal is making it hard to eat or drink, consider freezing a sports drink or juice in an ice cube tray and sucking on the cubes. You may use this technique with simple ice cubes as well.
Keep isopropyl alcohol nearby
Experts believe that sniffing a bit of isopropyl alcohol can significantly relieve withdrawal-related nausea. Ensure to keep a safe distance so the substance does not come in contact with the nose.
Try relaxation exercises
This tip is easier said than done, especially for a person going through a withdrawal. The key is to engage in anything that relaxes you, such as a warm bath, a good book, or some soothing music. Others may find relaxation in playing video games, meeting friends or family, stretching, or watching their favorite shows.
Some people may consider self-treating their symptoms on their own with personally-sourced opioids. While this is highly not recommended, people who still want to go ahead with it must test their supply with fentanyl strips while keeping in mind that these strips may not detect the presence of any contaminants. Moreover, it is imperative to attempt the process in someone’s presence and have naloxone nearby with an understanding of how to use it if an emergency arises.
Precipitated Withdrawal: How to Spot an Emergency?
In most cases, a precipitated withdrawal can lead to an agonizing experience that is necessarily not life-threatening. However, there is always a risk of things going wrong, especially in people with co-existing health issues. If you or someone you know starts experiencing one or more of the following symptoms during a precipitated withdrawal, consider seeking emergency help right away:
- Trouble staying awake and coherent
- Chest pain
- Uncontrolled, jerky movements
- Unusual heartbeat
- Trouble breathing
- A feeling that the heart is skipping a beat
- Stiffening of the body
- Loss of consciousness
If you are unsure about the alertness levels of a person undergoing a withdrawal, consider asking the following questions:
- What is their name?
- What city are they present in?
- What is their relationship to you? (For example, how do we know each other?)
- What is the name of the country’s president or any other famous personality?
If a person struggles to answer these simple questions, their answers are obscure or they are becoming less clear with time, call for help to ensure their safety.
FAQs
how long do precipitated withdrawals last?
A precipitated withdrawal may last several hours to several days without seeking any intervention. The exact timeline may depend on several individual factors, such as a person’s history of opioid use, metabolism, and general health. A specialist can consider these factors and provide an estimated timeline for the precipitated withdrawal symptoms; however, these timelines are also not confirmed.
How dangerous can a precipitated withdrawal be?
While precipitated withdrawal can rarely prove fatal, most people require hospitalization to overcome it, sometimes leading to admission to an intensive care unit. Dehydration is likely to be one of the most dangerous symptoms of this withdrawal. Hence, most people in hospitals begin treatment on IV fluids as experts monitor them for any additional health threats during the course of this withdrawal. Some doctors may also consider administering small doses of buprenorphine or Suboxone as it may override the existing withdrawal symptoms or lessen the overall severity. Additionally, some people may need sedation or general anesthesia due to severe agitation and anxiety for the entire duration of the process.
Who is at risk of experiencing a more serious precipitated withdrawal?
Individuals with a pre-existing history of health conditions or issues are more likely to develop severe complications secondary to a precipitated withdrawal. Hence, they need stricter monitoring to ensure that no unnecessary risks occur.
Is it possible to stop precipitated withdrawals?
Studies have shown that providing buprenorphine in very small doses or topping up their plan with additional doses of Suboxone can sometimes help stop the symptoms. Small, constant doses of either of these medications may successfully override the precipitated withdrawal symptoms while decreasing their duration and severity.
