Is ketamine indicated for Suboxone (buprenorphine) withdrawal?

From the Guidelines

Ketamine is not indicated for Suboxone (buprenorphine) withdrawal management. The standard approach for managing buprenorphine withdrawal involves supportive care and symptom management with medications like clonidine for autonomic symptoms (0.1-0.2mg every 6 hours as needed), loperamide for diarrhea (4mg initially then 2mg after each loose stool), ondansetron for nausea (4-8mg every 8 hours as needed), and non-opioid pain relievers like NSAIDs for pain and discomfort. While ketamine has shown promise in some pain management and depression treatment contexts, it has not been established as a standard treatment for opioid withdrawal syndromes, including those from buprenorphine, as noted in recent guidelines 1.

Buprenorphine withdrawal can be particularly prolonged due to the medication's long half-life and high receptor affinity, typically lasting 2-4 weeks with symptoms peaking around days 3-5. The safest approach is gradual tapering of buprenorphine under medical supervision rather than abrupt discontinuation, which can reduce withdrawal severity. If withdrawal management is needed, patients should consult addiction medicine specialists or healthcare providers experienced in opioid dependence treatment. Ketamine's use is more closely associated with the management of suicidal ideation in patients with major depressive disorder, as suggested by guidelines 1, but its application in opioid withdrawal is not supported by current evidence.

Key considerations in managing buprenorphine withdrawal include:

• Gradual tapering of the medication to minimize withdrawal symptoms
• Supportive care, including hydration and nutritional support
• Symptomatic treatment with medications like clonidine, loperamide, and ondansetron as needed
• Close monitoring by healthcare providers experienced in addiction medicine
• Avoidance of abrupt discontinuation, which can exacerbate withdrawal severity. The most recent and highest quality study on the topic does not support the use of ketamine for Suboxone withdrawal management 1, emphasizing the importance of evidence-based practices in clinical decision-making.

From the Research

Ketamine for Suboxone Withdrawal

• Ketamine has been studied as a potential treatment for precipitated opioid withdrawal (POW), including cases where Suboxone (buprenorphine) is involved 2, 3.
• Research suggests that ketamine may be effective in reducing opioid withdrawal symptoms, including those associated with Suboxone withdrawal, due to its ability to potentiate μ-opioid receptor-mediated signaling 2, 3.
• A case report published in the Journal of Addiction Medicine found that ketamine infusion, in combination with buprenorphine, was effective in treating a patient with severe opioid use disorder who experienced precipitated opioid withdrawal after taking Suboxone 2.
• Another study published in the same journal reported a synergistic effect of ketamine and buprenorphine in treating buprenorphine precipitated opioid withdrawal in a patient with fentanyl use 3.
• A pilot case series published in Addiction Science & Clinical Practice explored the use of ketamine-assisted buprenorphine initiation and found that sublingual ketamine at a sub-dissociative dose allowed completion of buprenorphine initiation in the outpatient setting in the majority of patients who reported trying it 4.

Mechanisms and Efficacy

• The exact mechanisms by which ketamine exerts its therapeutic effects in addiction, including Suboxone withdrawal, are not fully understood, but may involve enhancement of neuroplasticity and neurogenesis, disruption of relevant functional neural networks, and treatment of depressive symptoms 5.
• While the current evidence is promising, further research is needed to confirm the efficacy of ketamine for Suboxone withdrawal and to develop reliable protocols for its use in various treatment settings 2, 3, 4.
• Ketamine has been shown to be effective in reducing craving and self-administration of cocaine, heroin, and alcohol, and may have potential as a treatment for other addictions 5.

Clinical Applications

• Ketamine may be a useful adjunct to buprenorphine treatment for patients experiencing precipitated opioid withdrawal or severe withdrawal symptoms 2, 3.
• The use of ketamine in the outpatient setting, particularly at sub-dissociative doses, may help reduce patient apprehensiveness and increase the likelihood of successful buprenorphine initiation 4.
• Further research is needed to determine the optimal dosing and administration protocols for ketamine in the treatment of Suboxone withdrawal 2, 3, 4.