Revisiting Suboxone: How Long to Wait After a Heroin Relapse

Introduction

If you find yourself in a situation where you've been taking suboxone regularly but then relapse on heroin, the timing of restarting your suboxone is crucial. This article will guide you through the necessary steps to safely reintroduce suboxone into your system after a heroin relapse.

Continue Suboxone as Prescribed if You're Already on It

When you already have suboxone in your system, it is critical to continue using it as prescribed. Suboxone typically stays in your system for 24 to 48 hours. However, if you wait longer than this period, you should wait until you are undergoing withdrawal detoxification (w/d). Restarting suboxone too early can cause precipitated withdrawal. Precipitated withdrawal occurs when suboxone's strong affinity for the receptors causes a stronger withdrawal than would naturally occur, effectively knocking other opioids out of the receptors and causing withdrawal symptoms.

Why Suboxone and Subutex Cause Precipitated Withdrawal

Suboxone and Subutex (brand name for buprenorphine) both cause precipitated withdrawal through their interaction with opioid receptors. The buprenorphine component binds strongly to these receptors, knocking out other opioids. This mechanism is why opioid withdrawal symptoms can be exacerbated if suboxone is started too soon. Conversely, suboxone or subutex is less likely to cause precipitated withdrawal if your system already contains some buprenorphine, as it will not have the same strong effect in knocking out existing opioids.

Understanding Naloxone's Role

Naloxone, a component of subutex, is an inactive form when swallowed. It serves as an abuse deterrent to prevent intravenous injection. In cases of an overdose (OD), naloxone is administered either by injection or intranasally. It is important to note that oral administration of naloxone does not cause full withdrawal, as it would if administered intravenously.

Guidelines for Induction of Suboxone

The primary consideration in determining when to restart suboxone after a heroin relapse is the severity of your withdrawal symptoms. While a doctor or nurse can make an accurate diagnosis, if you are self-managing, start suboxone when your withdrawal symptoms become as severe as you can tolerate. A simpler approach is to start taking suboxone when your withdrawal symptoms reach a certain intensity, such as when you are in mild withdrawal with a Clinical Opiate Withdrawal Scale (COWS) score of at least 12.

Factors to Consider After a Heroin Relapse

How long you remained on heroin and the timing of your last dose play a significant role in deciding when to reintroduce suboxone. If you only took a couple of heroin hits shortly after beginning suboxone, it's likely that the suboxone would have blocked the effect of the heroin, allowing you to resume suboxone immediately.

After a period of abstinence from suboxone where you became dependent on heroin, a safe approach would be to wait approximately 24 hours after your last dose to start suboxone again, thus avoiding precipitated withdrawal. However, the most reliable method is to wait until you experience mild withdrawal symptoms, ensuring that the suboxone dosing is more effective and less likely to cause an exacerbation of withdrawal symptoms.