Not long ago we successfully detoxed a patient off Suboxone®. Sally (not her real name) started with oxycodone after surgery and when she developed a tolerance to these opioids, she turned to heroin. She used heroin for five years until she became pregnant and was put on Subutex®. After the pregnancy, she was switched back to Suboxone®. Her treatment never included counseling or therapy. She came to us to help her get off 16mg of daily Suboxone®.

The accelerated or rapid opioid detox program at the Coleman Institute for Addiction Medicine (not to be confused with an ultra-rapid detox which includes being under general anesthesia) involves small daily intra-muscular injections of naltrexone to slowly displace the existing opioids from the mu-opioid receptors.

Basically, we are inducing a low-level, controlled withdrawal. Depending on the amount of time a person has been dependent, and the amount and type of substance(s) they have been using, we will determine the appropriate length of their detox. This usually falls between 3 and 10 days. In certain circumstances, we will extend for a couple more days.

(By the way, another feature patients love about our detox is that it is done on an outpatient basis. This allows our patients to have their support person at their side 24/7. They can stay in their homes, a hotel or a local Airbnb.)

Our program detoxes people off pain medications such as Oxycontin®, Vicodin®, Percocet®, Dilaudid®, and fentanyl. We also detox people off long-acting agonists such as methadone and buprenorphine products, when people are ready to move to Medication Assisted Treatment (MAT) using naltrexone, a non-addictive opioid antagonist. Of course, we also detox people off heroin.

At the end of our detox process, we place a 1.4gram naltrexone tablet under the subcutaneous tissue in the abdominal area. Most people have enough of a fat layer (even the thin ones) for the implant to sit comfortably. It will immediately begin to dissolve and release about 12.5 mg per day of naltrexone to the opioid receptors, relieving a person of physical cravings. Most naltrexone implants will last at least eight weeks.

To be honest, the detox with us, and the placement of the naltrexone implant is the easiest part of our patients’ decision to stop using opioids. With physical cravings and the fear of withdrawal off the table, it is time to begin the process of unpacking the psychological aspects of the substance use disorder.

Sally came for a follow-up visit a few days after her detox. She had been experiencing quite a lot of nausea and restlessness. She was fearful she was having a reaction to the implant and was not sure she wanted to continue with long-acting naltrexone as her treatment. Her husband, delighted that finally, finally, his wife was off drugs, concurred. “She’s doing great! It was her idea to get off drugs in the first place; why do we need to bother to keep getting naltrexone?”

It’s a really, really good question.

We know that the brain can have physical changes with repeated heroin use. The National Institute on Drug Abuse has studied this extensively.

“Repeated heroin use changes the physical structure13 and physiology of the brain, creating long-term imbalances in neuronal and hormonal systems that are not easily reversed.14,15 Studies have shown some deterioration of the brain’s white matter due to heroin use, which may affect decision-making abilities, the ability to regulate behavior, and responses to stressful situations.”


Suboxone® is a combination of buprenorphine and naloxone and is classified as a partial agonist. This simply means that one component is an opioid and occupies the opioid receptor, mildly ‘turning it on’, while another component stands by to push opioids off the receptors (provokes withdrawal) if a person is taking the Suboxone® in a way it was not intended to be taken (i.e. snorted, injected, etc.).

We don’t really know the long term effects of buprenorphine on the brain.

Assuming that Sally’s brain has been occupied by some type of opioid for the last eight years, even though the buprenorphine has modulated the spiking dopamine levels caused by heroin, it’s likely her decision-making abilities and response to stress will be somewhat affected. Furthermore, Sally’s previous MAT treatment program did not include therapy to help her develop coping skills.

What will happen when the baby has a crying meltdown in the grocery store, financial stressors compound, her husband plucks her nerves…and she happens to run into an old ‘friend’ who previously supplied her with pills?

We know that Sally is motivated. We know her husband is a solid resource. She expressed commitment to attending recovery meetings and counseling, but at the time I saw her, she hadn’t started either. Caring for a young child, managing a household, and working part-time consumes most of her free time.

Using long-acting naltrexone may be the perfect bridge for Sally right now. While I have had several patients describe the side effects of nausea in the first few days of being on naltrexone, most people say that it goes away quickly. The freedom they feel of knowing they can’t use an opioid is well worth the tradeoff of a few days of feeling nauseated.

We will work with Sally, whatever she decides to do. My hope is that her nausea will clear up shortly (it is an awful feeling, I know), but to this day—twelve years in — I have not had a patient with a true allergic reaction to naltrexone. Weighing the pros and cons, it may make more sense for Sally to continue with long-acting naltrexone as she creates her recovery program, including counseling and/or recovery meetings.

If you have any questions about getting off buprenorphine or other addictive substances, please give us a call.

Joan R. Shepherd, FNP