The syndrome of physical dependence consists of two separate and related syndromes: tolerance and withdrawal. Individuals who use certain types of drugs for more than a few weeks may develop physical dependence on them as a result of developing both tolerance and then later withdrawal symptoms.
Tolerance occurs when the initial dose of a drug that a person had been taking no longer produces the same effects that it once did. The individual’s system has habituated itself to the drug, and the person needs to use more of the drug to get the same or similar effects that they once got at lower doses. When drugs are used medicinally and individuals develop tolerance, physicians prescribe mildly higher doses of the drug to the individual so they can experience the medicinal effects of the medication. Individuals who abuse drugs often rapidly increase the amount of drug they are taking once they begin to develop tolerance, and this results in a spiraling situation where the person needs extremely high doses of the drug to experience its effects.
People who use opiate drugs for medical reasons under the supervision of a physician are likely to develop physical dependence on them. However, a person developing physical dependence on an opioid drug that is used to control chronic pain associated with an injury or condition such as arthritis is not considered to have a substance use disorder (substance abuse or addiction), as long as they continue to use the drug as prescribed and under the supervision of their doctor. Substance use disorders represent the nonmedicinal use of drugs, such as heroin or OxyContin, (the person uses them for their psychoactive effects) that results in a reduction in the individual’s functioning, significant distress, and/or significant impairment in life. Even though their drug use results in numerous negative ramifications, these individuals continue to use the drug, also exhibiting a lack of control over use.
Opioid replacement drugs like Suboxone are designed to assist with the withdrawal process for individuals who have developed physical dependence on drugs by either abusing them or using them medicinally.
Opiate or opioid drugs (also often referred to as narcotic medications or narcotic drugs) are a large class of drugs that are primarily used in the control of pain but also have other medical uses. All of these drugs are either synthesized from the poppy plant or synthetically produced from analogs of substances in the poppy.
Opioid drugs include very familiar drugs, such as heroin, morphine, codeine, OxyContin, Vicodin, Norco, etc. These drugs may produce strong feelings of euphoria and have a significant potential for abuse in addition to their significant medicinal uses. They also have a very strong potential to produce physical dependence individuals who use them for more than a few weeks.
While the syndrome of physical dependence on opiate drugs is not considered to be potentially fatal, there are dangers involved when an individual goes through the withdrawal process from opioid drugs. The major dangers associated with the withdrawal process from these drugs are physical complications, such as dehydration, that can be potentially physically dangerous or a person committing self-harm either intentionally or unintentionally as a result of the emotional distress that the withdrawal process produces. The risk of relapsing during the withdrawal process from opioid drugs is very high because individuals become physically ill and emotionally distraught, and simply using their drug of choice will relieve the symptoms rather quickly.
Drugs used in opioid replacement therapy were designed to mimic the action of the more dangerous opioid drugs and, at the same time, reduce the withdrawal symptoms. The most known of these drugs is methadone; however, methadone is highly addictive itself. The development of Suboxone was designed as an alternative to drugs like methadone. Suboxone was not believed to be as salient a drug of abuse as methadone. However, individuals still can abuse Suboxone. Suboxone attempts to address the symptoms of withdrawal in individuals with physical dependence on opioids by combining two specific drugs: naloxone and buprenorphine.
The primary ingredient in Suboxone is buprenorphine, which is a partial opioid agonist. Partial opioid agonists bind to the same receptor sites in the central nervous system as other opioid drugs (which are full opioid agonists) but do not produce effects that are as strong as the effects of other opioid drugs. The use of partial opioid agonists tricks the brain into believing that the full opioid agonist is present, and the individual does not experience withdrawal symptoms. In addition, buprenorphine is long-acting and remains on these receptor sites for almost 24 hours, so if an individual takes a full opioid agonist, it will have no effect (called the ceiling effect). Once the person has taken the full dose of Suboxone, they will get no further effects from taking any other opioid drug, no matter how potent it is.
Withdrawal Timeline for Suboxone
The use of Suboxone is likely to result in physical dependence, whether the individual takes it medicinally or abuses it. Physical dependence occurs on the buprenorphine in Suboxone; not on the naloxone. When used as an opioid replacement medication during the withdrawal management process for individuals with substance use disorders, physicians use a tapering strategy where they administer decreasing doses of Suboxone to the person at specific time intervals in order to allow the person’s system to get used to decreasing levels of the drug. This results in a total elimination of withdrawal symptoms from the opioid drug the individual was using or a significant decrease in their intensity; however, the use of a tapering strategy in the withdrawal management process also extends the length of the withdrawal period.
The timeline presented in this article is based on an individual who abruptly stops using buprenorphine.
- Due to the longer half-life of Suboxone compared to other opiate drugs, the symptoms of withdrawal typically do not begin until 2-4 days following abrupt discontinuation of the drug. Withdrawal from shorter-acting opiate drugs like heroin may begin within 6-12 hours after last use. The symptoms during the initial phase of withdrawal most often consist of:
- Dilated pupils
- For the first week after an individual stops using Suboxone, they often will experience pain in their joints and muscles, muscle cramps, mood swings, anxiety, and flulike symptoms. Individuals are often very restless, irritable, and cannot sleep. They may not eat or drink, and if they are vomiting or have diarrhea, this can lead to issues with dehydration. Some people may become very emotionally distraught in the initial phases of the withdrawal process.
- Following the end of the first week through the end of the second week after stopping the drug, symptoms will decrease in their intensity. The person may still experience issues with mood swings, restlessness, problems with motivation, and mild flulike symptoms.
- Sometimes, within the third to fourth week after the person stopped using Suboxone, the withdrawal symptoms should be either complete or nearing completion. Some individuals still experience issues with pain, restlessness, and depression for several weeks.
The person will most likely experience cravings at all stages of the withdrawal process. It is not uncommon for individuals who have recovered from a substance use disorder to experience intermittent cravings for their drug of choice weeks, months, and even years following discontinuation. Cravings are often triggered by environmental conditions of drug use (e.g., being in places where, or with people with whom, they abused drugs), internal states (e.g., stress), and other conditions that are associated with one’s past drug use.
Many sources describe a syndrome known as post-acute withdrawal syndrome (protracted withdrawal syndrome) that occurs following the acute withdrawal effects from alcohol and drugs. This syndrome consists primarily of emotional symptoms, such as depression, anxiety, mood swings, a lack of motivation, irritability, boredom, restlessness, etc., and may last for weeks to even years. Post-acute withdrawal syndrome has never been accepted as being a formal withdrawal syndrome even though it is recognized that individuals recovering from substance use disorders remain at high risk for relapse and often experience a number of psychological issues that can trigger relapse.
Treatment for withdrawal from Suboxone is similar to the treatment protocol for the withdrawal process that occurs with other opioid drugs. Physicians initiate a tapering strategy where the person is administered Suboxone, and the dose is slowly tapered down to allow the person’s system to adjust to decreasing levels of the drug. Once the person is taking a minimum dosage, the drug is discontinued altogether.
Just going through detox is not sufficient to ensure the individual has recovered from their substance use disorder. Recovery from any substance use disorder typically involves lengthy participation in formal substance use disorder treatment, social support groups, and other interventions to address other issues or conditions that are present in the individual’s case. The relapse rate for individuals with substance use disorders in recovery is typically quoted as being between 40 and 60 percent; however, for individuals who just go through detox without a formal treatment program following, the relapse rate is nearly 100 percent.