Medically Reviewed By: Benjamin Caleb Williams RN, BA, CEN
Written By: Phillippe Greenough
Article Updated: 01/24/2021
Number of References: 9 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, including symptoms such as shakes, sweating, diarrhea, insomnia, anxiety, and depression. 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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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.
The timeline for Suboxone withdrawal can vary somewhat between individuals, but there is a generalized overview that may be true for the 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.
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.
A generalized overview of the Suboxone withdrawal timeline may look something like this:
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 is common, as is extreme restlessness. Yawning will be frequent as well, sometimes occurring several times a minute for hours on end. Appetite will decrease 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.
Some symptoms that can be expected during the first week of Suboxone withdrawal may include:
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.
Some symptoms that may be experienced during the second week of Suboxone withdrawal can include:
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 return to normal 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. The beginning of the fourth week often shows significant improvement. IF the physical symptoms are not fully resolved, they are usually very close to it. This can mark a transition from the acute phase 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 several more weeks although they will usually lessen in intensity as the weeks pass.
Some symptoms that may be expected to persist into the third and fourth weeks of Suboxone withdrawal can include:
The post-acute phase of Suboxone withdrawal is less physically intense but is a psychologically difficult time. Characterized by primarily psychological symptoms, it may be a very dark time for someone. 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:
Medications may be used to reduce these symptoms, and entering a treatment program 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.
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:
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.
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.
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.
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