Precipitated withdrawal or withdrawal symptoms that are instigated by taking another medication. For instance, if a patient has a dependency on fentanyl and has been regularly using, took an entire 8 mg buprenorphine dose, they would very likely develop moderate to severe withdrawal symptoms in response.
Why does Precipitated Withdrawal occur?
Precipitated withdrawal occurs due to a concept called “affinity”. You can think of affinity as the strength of a magnet with differing magnetic strengths. When the patient is using fentanyl or other opioids like heroin or oxycodone, that opioid has an affinity for the opioid receptor in their brain. When that opioid connects with the receptor, the result is dopamine release. Dopamine is the “happy hormone”. Different opioids have different strengths of affinity for the opioid receptors. Buprenorphine has a stronger affinity for the opioid receptors than fentanyl or other opioids. As a result, taking buprenorphine when you are dependent on another opioid like fentanyl will result in the buprenorphine displacing the fentanyl from the receptors, precipitating withdrawal symptoms. Most of the time precipitated withdrawal only lasts an hour or two and will resolve on its own.
Can I avoid Precipitated Withdrawal?
Historically, precipitated withdrawal could be avoided simply with time. Oxycodone for example would usually be metabolized off of the receptors within 12 hours. If the patient could wait 18 to 24 hours after their last oxycodone use, most of the receptors would already have metabolized the oxycodone and would be “open”. That patient could be safely administered buprenorphine because there was not any more oxycodone to displace.
This has become much more challenging with the use of fentanyl. Fentanyl seems to stick around in the system much longer than 24 hours and can even be in the system 3 or 4 days later. It is oftentimes unrealistic to have the patient be able to wait 3 or 4 days without any substance use in order to avoid precipitated withdrawal because they would already be in withdrawal! As a result innovative processes for the induction (transition from illicit opioid onto buprenorphine) like microdosing, we have some techniques that we will allow patients to get onto buprenorphine while minimizing precipitated withdrawal symptoms.
What is microdosing?
In the context of opioid use, microdosing is a technique we used for the induction process. Introduction of buprenorphine to a patient dependent on fentanyl or other illicit opioids will oftentimes cause precipitated withdrawal. Symptoms can be severe enough that they actually deter patients from continuing missing an opportunity for recovery.
The concept of microdosing is really nothing more than tapering down the opioid the patient is currently using while gradually titrating up buprenorphine. We have become quite adept at instructing our patients on how to do this successfully and would be happy to discuss it with you as well.
If you are struggling with chronic pain and opioid use and are looking for answers, please contact us today.
