Can Stopping Suboxone Cause Psychosis?
Yes, abrupt discontinuation of Suboxone (buprenorphine/naloxone) can precipitate new-onset psychosis, though this is a rare clinical phenomenon that appears to occur primarily in patients with pre-existing psychiatric vulnerabilities, particularly bipolar disorder or prior psychotic episodes. 1, 2
Evidence for Withdrawal-Induced Psychosis
The most compelling evidence comes from documented case reports:
A 41-year-old female with bipolar disorder developed new-onset psychotic symptoms and manic relapse following abrupt Suboxone discontinuation, which resolved with antipsychotic and mood stabilizer treatment during short-term hospitalization 1
Similar withdrawal psychosis has been documented with methadone (another opioid agonist), where patients developed psychosis during opioid taper without typical withdrawal syndrome features 2
In the methadone cases, two patients had no prior psychosis history, one had a remote psychotic episode 21 years earlier, and one had schizophrenia that remained asymptomatic on methadone alone 2
High-Risk Patient Populations
Patients at elevated risk for withdrawal-induced psychosis include:
- Those with bipolar disorder or other mood disorders with psychotic features 1
- Patients with prior psychotic episodes, even if remote 2
- Individuals with pre-existing CNS illness or schizophrenia 2
- Patients abruptly discontinuing rather than tapering 1
Critical Diagnostic Considerations
When evaluating suspected Suboxone withdrawal psychosis, the American College of Radiology recommends systematically excluding other causes 3, 4:
Rule out delirium first: Evaluate for fluctuating consciousness, disorientation, and inattention (delirium) versus intact awareness (psychosis) - missing this distinction doubles mortality 3, 4
Assess for withdrawal seizure risk: Alcohol or benzodiazepine co-withdrawal requires immediate benzodiazepine treatment to prevent life-threatening seizures 4
Temporal relationship is key: Establish that psychotic symptoms emerged specifically during or immediately after Suboxone discontinuation, not before 5, 6
Management Approach
For confirmed withdrawal-induced psychosis:
Antipsychotic treatment is typically required, with effects becoming apparent after 1-2 weeks and full trial requiring 4-6 weeks 4
Mood stabilizers should be added if manic symptoms are present 1
In some cases, resumption of the opioid agonist may be necessary 2
Avoid large initial antipsychotic doses, as they increase side effects without hastening recovery 4
Maintain continuity of care with the same clinicians for at least 18 months 4
Important Caveats
The Mayo Clinic Proceedings notes that buprenorphine has multiple drug-drug interactions that can result in QT-interval prolongation, serotonin syndrome, and precipitation of withdrawal symptoms 7. One case report documented severe serotonin syndrome from a single Suboxone dose in a patient on tricyclic antidepressants 8, highlighting that psychotic presentations may have multiple etiologies beyond simple withdrawal.
The proposed mechanism involves opioid agonist modulation of dopaminergic neurotransmission, though this requires further research 2. The rarity of this phenomenon suggests individual vulnerability factors play a crucial role.