Post-op Pain on Suboxone

Many patients on Suboxone or buprenorphine eventually require pain treatment, just like people who aren’t on buprenorphine products.  I’ve written about post-op pain control several times, but I continue to get emails from patients who haven’t seen my comments and who view an upcoming surgery with the same fear experienced by patients before the early 1900’s, when the OR was correctly seen as a horror-chamber.
These patients are often torn between following the treatment plan vs. doing what they have learned may work better.  In all cases, I tell patients that they cannot act in ways counter to what their physician prescribes.  But I often support their intent to ask their doctors to clarify or modify their treatment plans.
Patients write about ‘the look’– the way doctors, nurses, and pharmacists react when patients ask about pain control.  As a recovering addict myself, I know what they are referring to.   Doctors encourage other patients to discuss concerns about pain control, and as long as they have no piercing or tattoos, patients will usually be comforted with assurances that their doctors will take their pain seriously.  But people on buprenorphine often see their doctors roll their eyes, or even say that the opposite is true– that if they have pain, they had better not bother the doctor about it!    Doctors who act that way are asses, of course, and I urge patients to avoid them if possible.  This post is not for those doctors, as they are not likely to ‘get it’ after reading the comments of another doctor— if they would ever read them in the first place!
I’m writing for the doctors who are open to hearing about new ways to help their patients.  I intend to use this post, going forward, to answer the emails from patients about this topic   If you are a physician who received this from a patient, please consider my comments– as I have found the approach described below far more helpful for surgical patients on buprenorphine products than the alternatives described elsewhere.  There was an NIH consensus paper a few years ago for example that described several alternatives, but mostly focused on discontinuing buprenorphine before surgery, then restarting buprenorphine at some point through a standard induction that includes 24 hours of withdrawal in patients already weakened by surgery.  Standard doses of opioid agonists were recommended for pain.  That approach was also described in a flashy article in one of the throw-away journals a month or two ago (i.e. Autumn of 2015).
There are so many problems with that approach:

  • Patients forced to stop buprenorphine before surgery and enter surgery dehydrated and weakened (IF they even managed to stop, as many patients end up staying on buprenorphine covertly– NOT a good situation for surgery.)
  • Buprenorphine discontinuation not an option for emergency surgeries;
  • Constant opioid levels are necessary to avoid withdrawal, before even considering pain control;
  • Buprenorphine is erroneously considered gone, when the long half-life actually assures that buprenorphine is still present;
  • Patients fret and argue over pain control every time the nurses change shifts;
  • Buprenorphine re-induction at some point after surgery, requiring patients to go through withdrawal symptoms;
  • Agonist treatment alone causes tolerance to rise very rapidly, requiring high doses of narcotic at hospital discharge;
  • An increased risk of overdose from narcotic pain medication in patients off buprenorphine;
  • And many other reasons.  Using the ‘discontinuation’ approach, patients end up on a Hellish roller-coaster ride where pain is grossly under-treated and withdrawal symptoms are only 4 hours away, day after day.

I’ve read emails from people whose buprenorphine doctors recommended taking more buprenorphine for post-op pain, or dosing more often.  I’ve read about suggestions to use Tramadol for pain after major surgery(!)
Earlier today I sent a letter in response to a woman who is planning a series of painful procedures.  I’ll share that letter to spare myself some time:
Dear A,
You’ve been through enough misery, and I hope you convince your physician to consider a different approach to your pain. I’ve had patients on buprenorphine go through many surgeries including thoracotomy, nephrectomy, open cholecystectomy, total knee replacement, and rotator cuff repair– all very painful surgeries.  My experience as an anesthesiologist piques my interest in post-op pain control.
My favored approach is very simple.  Maintain buprenorphine, and use oxycodone or other agonists to out-compete buprenorphine at the mu receptor as needed for pain relief. The benefits of the approach are obvious once the prescriber opens his/her mind to the realities of ligand competition.  There is no need to go through withdrawal, no need for ‘comfort meds’ to tolerate the withdrawal, and no need to enter surgery in an already-weakened state. As you know, even minor withdrawal causes people to feel very depressed, lose their appetites, stop sleeping…. is that really any way to go into surgery?!
As an aside,  buprenorphine alone does not provide ‘real’ pain control in patients who take chronic buprenorphine.   Yes, buprenorphine seems to reduce pain in people with minor pain issues.  But it is of no use for the pain of major surgery.  Of course in theory, why would buprenorphine treat chronic pain in patients with complete mu tolerance to a medication with a ceiling effect?!
A few years ago, an NIH consensus paper described a few approaches to acute pain in patients on buprenorphine. I don’t know who was on that panel, but the paper suggested stopping buprenorphine for several days before surgery and then using agonists. The panel mentioned the approach that I favor near the end of the paper.   I also described my favored approach at an annual meeting of ASAM, in a talk that was very-well received. I was optimistic that the discussion would open enough minds among prescribers to follow the neurochemistry, instead of focusing on the misplaced fear of combining an agonist and a partial agonist.   There are other papers out there– and book chapters– about the effects gained by combining an agonist with a partial agonist. You can find my ASAM slides at www.slideshare.net by searching for ‘junig’ and ‘uncoupling analgesia’.
The ‘uncoupling’ part BTW is what makes my favored approach so valuable, but that gets into the area of chronic pain, which is not entirely relevant to this discussion.  In short, opioid analgesia has always been limited by tolerance and dependence.  I believe that those limits can be removed by combining mu receptor agonists with partial agonists, allowing for pain relief from agonists while partial-agonists prevent euphoria and anchor tolerance at a lower level.
My approach is to reduce buprenorphine to about 4 mg per day.   Higher doses in my experience get in the way of pain control.  I then treat post-op pain as I would in any patient, but using 4 times more agonist (warning– see * below).  I typically prescribe oxycodone, 15 mg tabs,* and direct patients to take one tab every 4 hours as needed. When patients no-longer needs narcotic analgesia, I stop the agonist and have them resume their regular doses of buprenorphine. That’s it.  No tapering, and no withdrawal… just treating patients as I would any other patients, but realizing that mu receptors are competitively blocked, and effective doses of oxycodone must out-compete buprenorphine.
Dilaudid or fentanyl are not necessary. You could approach post-op pain in a very elegant way in a hospital using sublingual buprenorphine, fentanyl infusion, and PCA, but that gets a bit complicated. Oxycodone works fine.   In rare cases my patients required higher doses of oxycodone, but I’ve never had reason to use more than 30 mg.   Oxycodone is typically used every 4 hours.  My buprenorphine patients have found good pain relief from total daily doses of 60-120 mg of oxycodone.  The patients who went to a hospital where I couldn’t control their analgesia, who were told to stop buprenorphine, ended up on much higher doses of oxycodone at discharge.
Advantages of Combined Approach:
There are many advantages to maintaining buprenorphine throughout the perioperative period. The entire process is much simpler, and the patient’s experience is better because there is no euphoria, and no warm rush from oxycodone to rekindle addiction. The pain is relieved, but the reinforcing effects of oxycodone are eliminated.  I assume the that the limits on mu effects by buprenorphine are like a ‘governor’ that limits the speed of fleet vehicles. You can get only so much opioid effect in the presence of buprenorphine, and not enough to cause a ‘high.’
The combined approach also prevents tolerance, which is a greater issue with chronic pain than with post-operative pain. Buprenorphine anchors tolerance at the level yielded by the ceiling effect, allowing agonist effects to continue over time. I’ve treated people with the combination of buprenorphine and oxycodone for over 2 years, and the combination continues to work as well as it did on the first day.
Some prescribers and pharmacists worry about ‘precipitated withdrawal’, but that is not an issue as long as buprenorphine is continued every day. The only way to precipitate withdrawal would be to stop buprenorphine for at least a few days, boost tolerance higher with an agonist, and then give buprenorphine– which would ‘yank’ tolerance back down again. Patients who stay on buprenorphine can add agonists without fear of precipitated withdrawal.
I’ve convinced a few doctors to try this approach, and I’ve received a number of positive reports about the approach.   I’ve described the idea to several pharmaceutical companies as an approach that would revolutionize pain treatment.  Can you imagine pain relief without addiction, without tolerance, and without euphoria?   I realize that the large number of deaths caused by opioid overdose limits interest in opioid analgesia.  But I suspect that a product that combines buprenorphine and an agonist would go a long way to reducing opioid dependence, providing that the two medications were irreversibly bonded together in a combination product.  I have some thoughts about how to do that… but that’s for another day!
It is NEVER safe to prescribe one’s self opioids or other controlled substances, so this discussion is intended to provoke discussion between patients and their doctors.  Patients must realize that there are many things that go into decisions about post-operative analgesia, and NO approach is the right approach for everyone.  Any individual patient may have features to his/her history that make the combination approach inappropriate, or even dangerous.
*Doses described in this post are intended as approximations for consideration by trained and licensed medical professionals.  Doses described may not be safe in some patients, including patients at the extremes of age, patients with respiratory or other chronic illness, patients with central nervous system disorders, or patients on other respiratory depressant medications.
NEVER use opioids except as directed by your own physician.

Post-op Pain on Suboxone

I often receive emails from patients on buprenorphine (or Suboxone) who are preparing for surgery or other painful medical procedures. Ideally in such cases, the surgeon would have a discussion with the person prescribing buprenorphine, in order to coordinate the plan for treating postoperative pain. In practice such discussions don’t seem to take place, leaving patients to scramble for effective pain control after surgery– when it is too late to take the steps necessary for a smooth perioperative course.
I am familiar with an NIH article that describes pain control in people who take buprenorphine. I’ve also prepared a handbook that describes the issues that must be considered in such patients; the handbook can be found easily-enough by searching for the User’s Guide to Suboxone.
Even with those descriptions ‘out there,’ I’ll get requests for a short, ‘just-the-facts’ note that patients can give to their surgeons. I realize that unfortunately, the average surgeon will not sit down for an in-depth discussion of post-op pain control, so I have prepared a few paragraphs that lay out the issues. People on buprenorphine who are having surgery are welcome to copy the paragraphs below and give them to their surgeons, in order to facilitate discussion.
Surgery in Patients on Buprenorphine
Buprenorphine is a partial opioid agonist that is used for several indications. In low doses—less than 1 mg—buprenorphine is used to treat pain (e.g. Butrans transdermal buprenorphine). In higher doses i.e. 4 – 24 mg per day, buprenorphine is used as a long-term treatment for opioid dependence and less often for pain management. At those doses, Buprenorphine has a unique ‘ceiling effect’ that reduces cravings and prevents dose escalation. Patients taking higher dose of buprenorphine, trade name Suboxone or Subutex, become tolerant to the effects of opioids, and require special consideration during surgical procedures or when treated for painful medical conditions.
There are two hurdles to providing effective analgesia for patients taking buprenorphine: 1. the high opioid tolerance of these individuals, and 2. The opioid-blocking actions of buprenorphine. The first can be overcome by using a sufficient dose of opioid agonist, on the order of 60 mg per day of oxycodone equivalents or more. The second can be handled by either stopping the buprenorphine a couple weeks before agonists are required—something that most patients on the medication find very difficult to do—or by reducing the dose of buprenorphine to 4-8 mg per day, starting the day before surgery and continuing post-operatively. Given the long half-life of buprenorphine, it is difficult to know exactly how much remains in the body after ‘holding’ the medication. That fact, along with the difficulty patients have in stopping the medication, leads some physicians to use the latter approach- i.e. to continue 4 mg of buprenorphine per day throughout the postoperative period. People taking 4-8 mg of daily buprenorphine report that opioid agonists relieve pain if taken in sufficient dosage, but the subjective experience is different, in that there is no feeling of euphoria.
Quick Notes:
Patients taking maintenance doses of buprenorphine do NOT receive surgical analgesia from the medication, as they are completely tolerant to the mu-opioid effects of buprenorphine after the first week or so on the medication.
Discontinuation of high dose buprenorphine or Suboxone treatment results in significant opioid withdrawal symptoms within 24-48 hours.
Normal amounts of opioid pain medication are NOT sufficient for treating pain in people on buprenorphine maintenance.
Opioid agonists will NOT cause withdrawal in people on buprenorphine. Initiating buprenorphine WILL cause withdrawal in someone who is tolerant to opioid agonists, unless the person is in physical withdrawal before initiating buprenorphine.
Non-narcotic pain relievers CAN and should be used for pain whenever possible in people on buprenorphine to reduce need for opioids.

Is My Suboxone Dose Too High to Have Surgery?

Thanks, all of you who wrote comments to my last post.  I remind everyone once again to consider taking your comments here and after writing them, also taking them to SuboxForum.com.  I am going to put up a new category to discuss topics that were initiated here;  it would be great to get a spirited, respectful ‘give and take’ on some of these topics.  As I have mentioned before, the only thing that I will block on that site would be debating whether people on Suboxone are ‘in Recovery’– just because there are plenty of other sites for that, and I want the forum to be for people who have made their decision– and don’t want to be harassed over it.  I will be upgrading that site shortly and changing the hosting account;  hopefully I will pull it off without erasing everything!
OK, tonight’s topic: I am taking my post from a different forum and posting it here also to save wear and tear on my keyboard…  I responded to a person who is taking 32 mg of Suboxone daily and who is concerned that the relatively high dose will raise her tolerance higher than she would like.  She has surgery coming up, and is concerned that the high tolerance will get in the way during or after the surgery.    My reply addresses the level of opiate tolerance in relation to dose of buprenorphine.  Incidentally though I will quickly say that buprenorphine poses little problem during an anesthetic;  it does not interfere to a large degree with general, epidural, or spinal anesthesia.  But buprenorphine DOES interfere with the treatment of post-operative pain.  I will also comment that I consider 32 mg of daily Suboxone to be a waste of money;  my experiences treating people with Suboxone have only reinforced my opinion that there is no benefit, and often considerable harm, in taking more than 16 mg of Suboxone per day,  and in dosing more than once per day.  But that discussion will have to wait.
My Response:
I will talk about buprenorphine, the active medication in Suboxone, just to simplify things a bit– although Suboxone will have the same effects. First, when talking about the dose, it is important that the method one takes it is identified– as that is what determines how much active drug ends up in the bloodstream. I will assume that the person is taking steps to get maximal absorption of Suboxone; for example keeping it exposed to mucous membranes for a long-enough time, and not rinsing the mouth with liquid for at least 15 minutes after dosing, to avoid rinsing away drug that is attached to the lining of the mouth but not yet absorbed. As an aside, there is a post somewhere on this blog entitled ‘maximizing absorption of Suboxone’ for those who want more info.

When a person takes Suboxone, he is taking a ‘supra-maximal’ dose of buprenorphine. Buprenorphine is used to treat pain in microgram doses; the BuTrans patch is used in the UK to treat pain, and it releases buprenorphine at a rate of 5-20 MICROGRAMS per hour! One tablet of Suboxone containes 8000 micrograms! So whether a person is taking one, two, three, or more tabs of Suboxone per day, he is taking a very large dose of buprenorphine— a dose large enough to ascertain that he is up on the ‘ceiling’ of the dose/response curve. It is important to be on the ceiling, as this is the flat part of the curve (I know– a silly statement) so that as the level of buprenorphine in the bloodstream drops, the opiate potency remains constant, avoiding the sensation of a decreasing effect which would cause cravings.


I have read and heard differing opinions on the dose that gets one to the ‘ceiling’ but from everything I have seen the maximal opiate effect occurs at about 2-4 mg (or 2000-4000 micrograms), assuming good absorption of buprenorphine. I base this on watching many people initiate Suboxone; if a person with a low tolerance to opiates takes 2 mg of buprenorphine, he will have a very severe opiate effect; if he takes that dose for a few days and gets used to it, and then takes a larger dose, there is no significant increase in opiate intoxication– showing that once he is used to 2 mg, he is used to 16 mg— and is ‘on the ceiling’ by definition. I see the same thing in reverse; there is very little withdrawal as a person decreases the dose from 32-24-16-12-8 mg, but once the person gets below 4 mg per day, the real withdrawal starts. This again shows that the response is ‘flat’ at those high doses, and only comes down below about 4 mg of buprenorphine.

The flip side of all of this is that tolerance reaches a maximum at about 4 mg of buprenorphine, and further increase in dose of buprenorphine does not cause substantial increase in tolerance. Tolerance and withdrawal are two sides of the same coin; the lack of withdrawal going from 32 to 8 mg of buprenorphine is consistent with no significant change in tolerance across that range.

So in my opinion, being on 32 vs 4 mg of Suboxone doesn’t raise your tolerance. But in regard to upcoming surgery, there is an additional concern. One issue with surgery on buprenorphine is the high tolerance, but the second issue is blockade of opiate agonists by buprenorphine– and this effect is directly related to the dose of buprenorphine. A person on 32 mg of Suboxone will need much, much higher doses of agonist to get pain relief than will a person on 4 mg of Suboxone– not because of tolerance but because of the blocking effect, which is competitive in nature at the receptor. When people are approaching surgery I recommend that they lower their dose of Suboxone as much as possible– to 4-8 mg if possible. Because of the very long half-life (72 hours), this should be done at least a week before the surgery. Then I have them stop the Suboxone three days before the surgery; it usually takes 2-3 days for significant withdrawal to develop. I say all of this to give a general sense of the issues involved; people should discuss the issue with their physician rather than act on what I am describing here.

Having Surgery: When to Stop Suboxone?

A question about Suboxone and Surgery:
Hi-this is in reply to your message back to me. I am the girl who is soon to have surgery. You said that 3 days would be good to be off the suboxone, but you said the worst withdrawal takes about 3 days to hit, so it’s a bit of a compromise. But, won’t the withdrawal be halted once the pain medication gets into my body? Are you just saying that I will have to deal with some detox discomfort during the 3 day period? I, unlike many people, know quite a bit about suboxone (it is so surprising how many people are clueless), but the one thing I am not clear on is how long it would take to “feel” opiates after stopping suboxone (thank God I am ignorrant in this area!). On one of your blogs you said that opiates would work as short as a day afterwards, but that you would have to have quite a bit to get past the buprenorphine. I just dont think I can go off of them for 3 days prior to surgery. I am on 16 mg 2x a day.
My Response:
You are on a pretty large dose of Suboxone.  Everything is relative, but about 4 months ago the manufacturer of Suboxone sent a notice to doctors and pharmacists saying that because of the ceiling effect of buprenorphine, and because of the diversion of the drug, the maximum dose should be no more than 16 mg per day. The notice went on to state that a rare patient may require doses of up to 24 mg for a very short period of time, but that higher doses were never indicated.
In my local area, one clinic uses a max dose of 4 mg per day, a dose that I consider to be too low, but in my own practice I almost never use doses about 16 mg per day.  Overall, 30% of my patients take 8-12 mg per day, 60% take 12-16 mg per day, 3% take 16-24 mg per day, and the remaining 7% (7 patients) take less than 8 mg per day.
If the dose is taken correctly so that maximum uptake occurs, there is no subjective difference between 8 and 16 mg per day.  I have taken a number of people down in dose from 16 to 8 mg, and there is never any significant withdrawal;  there is, though, the ‘imaginary withdrawal’ that happens so much with early use of Suboxone. What is the difference?  Real withdrawal lasts until the person takes another dose;  the ‘imaginary withdrawal’ comes in waves, and then disappears as soon as the person is distracted a little bit.
Grrl, I strongly recommend that you get your dose down to 8 mg or so per day before surgery.  The blockade of the receptor is competitive;  it will be almost impossible to get enough agonist to overcome the blockade of 32 mg of daily buprenorphine.  Yes, 1000 mg of oxycodone might do it, but you will never get anyone to give you that amount in a hospital.  Even the less-ridiculous doses are hard to get, as every person in the chain gets in the way.  The surgeon doesn’t want to write for such high doses, as he doesn’t want to take the time to explain why he is doing so to all of the people who will be calling him.  The unit secretary doesn’t want to transcribe the order until she calls the surgeon to say, ‘are you sure you want THIS MUCH?’  Then the nurse won’t want to  give such a large dose, especially without monitoring– meaning that he/she will suddenly be pushing to get you transferred to the ICU.  The pharmacist may nix the whole thing, and simply say that ‘he isn’t going to risk his license by releasing so much narcotic’. Meanwhile, you will be writhing in pain as the hours go by.
The lower you can get your daily dose, the less buprenorphine you will have in your body to block the post-op medications.  Yes if you stop entirely three days in advance, you won’t have significant withdrawal for a few days… and by that time you will be getting the post-op pain meds.
A couple things… an anesthesiologist wrote and said that in his experience the lipid-soluble and high-potency opiates seem to ‘compete’ more effectively at he opiate receptor, and that they therefore are better choices for post-op pain.  Remember, though, that you will have TWO problems with getting pain relief;  the first is the competetive block of your opiate receptors, and the second is the high tolerance you will be left with, even after the buprenorphine is gone.
Your last question about how long it would take to ‘feel’ agonists after Suboxone… it would depend, of course, on the dose of agonist, the type of agonist, and the dose of Suboxone.  The bottom line is that it always takes much longer than people expect.  I have had a couple people who needed to go back to agonists for pain, and they said something similar to each other– that even after weeks off the suboxone, they could never get the same old ‘euphoric’ feeling again.  I don’t know if that is from some small lingering amount of Suboxone, or from the remaining elevated tolerance persisting for a long time after stopping the drug… But whatever it is, it will be difficult to get relief from opiate agonists for some time after stopping Suboxone.  And the people who stop Suboxone for a day, hoping to catch a buzz from a couple 40’s, will be disappointed!

Surgery Preparations for a Suboxone Patient

The questions:
I am having surgery and my doc was unaware of some things and I thought that you could confirm them for him?  Could you advise him to take me off the Suboxone 10-14 days prior to surgery?  I have been researching this religously and I have come to the conclusion that it would take 2 weeks to get the Bupenepherine 100% out of my system so that there is no blockage, unless you think otherwise?  Also could you tell him about the oxycodone to keep me out of withdrawal and to help me cope with the pain?
Note:
I had also received a note from the doctor, saying that he was going to change the patient from Suboxone to Subutex before the surgery, and then back again at a later point.  This is fine, but not enough– the naloxone isn’t the problem– the buprenorphine alone is a partial agonist i.e. an antagonist at the mu receptor.  The buprenorphine alone will block other opiates, and since the patient is tolerant to the buprenorphine, it will not serve any role as an analgesic medication.  The patient needs additional opiate activity in order to have analgesia– and since his tolerance is high, he needs significant doses of a potent opiate.
My comments to the doctor:
Hi Dr. XXXX,

I don’t want to complicate your treatment of Mr. XXXX—he reads my blog about Suboxone at http://suboxonetalkzone.com where I write quite actively about my experiences treating patients for opiate dependence.  I am a (blah blah blah blah– you all know this stuff by now)

I have helped a number of patients through surgery.  The naloxone isn’t so much the problem as is the buprenorphine–  naloxone has a very short half-life and will cause a couple hours of withdrawal if injected IV, but buprenorphine is a partial agonist, and has very potent antagonism at the opiate receptor that lasts for days and days.  The half-life of buprenorphine is about three days;  when we treat addiction we are using supra-maximal doses of buprenorphine.  When I gave buprenorphine IV to treat labor pain as an anesthesiologist I would give microgram doses;  even just 8 mg is enough to block ordinary doses of opiate agonists for several days.


With my patients, or when recommending other physicians, I suggest first getting the patient to a lower dose of buprenorphine—on the order of 8 mg per day.  If you were to lower Mr. XXX’s dose tomorrow, he wouldn’t get down to a new steady-state level for at least a week or two;  he would have very little withdrawal, because the ‘ceiling effect’ occurs at a dose of about 4 mg per day, so any dose above that will have almost the same opiate activity.  From the 8 mg daily dose (usually once per day, in the morning) I stop the buprenorphine at least 3 days before surgery.  It will still be very difficult to treat post-op pain, because three days later the person will still have significant buprenorphine in his system, which has a very high affinity for the receptor.  It is important to remember that even if all of the buprenorphine was gone, the patient will still have a very high tolerance—equivalent to being tolerant to 30 mg methadone or 60 mg oxycodone.  That means that 60 mg of oxycodone only gets the patient to ‘neutral’;  higher doses are required to provide analgesia.  I usually give patients either 15 or 30 mg oxycodone tabs, to take 2 (or more) every 4 hours as needed.  At the time when the surgeon would typically stop narcotics, I change the patient back to Suboxone or Subutex—either one, as they both work the same in a person not injecting.

It is important to focus on the pain, not on the dose of narcotic. The dose is meaningless in a tolerant patient;  I have had patients require doses of morphine greater than 50 mg every 2 hours after c-section, for example.

On my blog I have a number of comments about anesthesia and surgery;  if you go to http://suboxonetalkzone.com and search for ‘anesthesia’ or ‘surgery’ you will find them.

Thanks for writing, and good luck.

Addendum for the blog readers:

I am aware that the person having surgery requested medication to prevent withdrawal; I did not mention this to the surgeon because it is a ‘touchy subject’. It is in fact illegal to prescribe or administer an opiate for the sake of treating withdrawal, with the exception of methadone clinics—and now Suboxone. For that reason, I don’t usually stop the Suboxone 10 days in advance—I stop it 3 days in advance. Most people seem to take about three days to go into withdrawal, so that usually works pretty well.

I have had a couple discussions with this writer, and I hope things work out well for him. Many doctors out there have their own ways of doing things, and most doctors consider themselves up on what they need to know; it is hard to just tell a doctor to ‘do it this way’. I know I wouldn’t like it either. Let’s all hope for a little extra consideration and sensitivity from his physician.

Pain Control After Surgery for Patients On Suboxone

The topic of post-op pain control on buprenorphine is important enough to get top billing
Many thanks to Dr. J Walsh in Seattle for the following post:
I am a physician in Seattle.  In two c-section cases we have found that high affinity opiates (fentanyl or hydromorphone) delivered by PCA can provide adequate anesthesia even while sublingual buprenorphine is continued.  Have you found similar results with those or other pain medications?

To provide some background, patients taking Suboxone, Subutex, or any other form of buprenorphine face a problem when they need pain control, particularly if the need is acute– after injury or surgery.  Buprenorphine is a ‘partial agonist’ at the mu opiate receptor;  it has a ‘ceiling’ to its effects, so that increases in dose of buprenorphine will not provide increased analgesia.  This is great for addiction treatment, as the addict has no reason to take extra buprenorphine.  But buprenorphine not only won’t be more effective in higher doses–  it also prevents other pain medications from working.  Again, this is a positive when it comes to treating addiction, as the addict will find oxycontin to be a complete waste of money (of course, it always WAS a waste of money!).  But for a person who just had his/her belly cut open, a bit of oxycodone can be quite valuable!
Many of my buprenorphine patients have had surgeries for one thing or another.  My approach is to increase the dose pain medication used after surgery by about two- or three-fold.  The receptor blockade from buprenorphine is ‘competetive’, meaning that it can be overcome by using high doses of potent narcotics.
I strongly recommend that patients on buprenorphine avoid increasing the dose of any pain medication beyond their doctor’s recommendations, as many people die from overdose every day, and trying to overcome the block from an opiate antagonist is asking for big trouble.  A small miscalculation can easily kill a person.  Buprenorphine patients who need intensive post-op pain control are usually put in the ICU where their resperation and other vitals can be monitored using pulse-oximetry and other devices.
I have had patients use morphine or oxycodone in high doses to get pain relief;  this writer reports success using high-potency opiates (he mentions fentanyl, the product in the skin patch ‘duragesic’ and a common anesthetic medication, and hydromorphone, AKA Dilaudid) by PCA– Patient Controlled Analgesia.  With PCA patients are usually given a constant infusion of narcotic and also have a button to push that provides a ‘boost’ injection on demand– with a ‘lock-out interval’ to prevent getting too much medication from pushing quickly and repeatedly.
Fentanyl and other high-potency narcotics are not used by nurses as often as are morphine and (unfortunately) Demerol. (Demerol is slowly being removed from many hospital formularies because of the toxicity of its principle breakdown product, normeperidine).  The high-potency opiates are more dangerous when given intravenously primarily because of their high solubility in lipids, or fatty material.  This solubility allows them to cross the ‘blood brain barrier’ much more quickly then water-soluble drugs like morphine, so that the effect is almost instantaneous– equal to one ‘arm to brain circulation time’, as we said back in the anesthesia days.  This causes in instantaneous shift in the response of the respiratory rate to carbon dioxide, causing the patient to stop breathing until the carbon dioxide level increases to the new threshold required to stimulate breathing.  During this pause in breathing, the patient’s oxygen level can drop to levels low enough to trigger a fatal arrhythmia– killing the patient.
Water-soluble opiates like morphine, on the other hand, enter the brain more slowly– over 5-15 minutes, even when injected intravenously.  The shift in the breathing response occurs more slowly, so the patient SLOWS his/her breathing, rather than just stopping–  allowing the carbon dioxide level to increase without having the oxygen level fall as dramatically.
The competetive interactions of molecules at receptors are much more complicated than visualized in the simple drawings used to teach introductory neurochemistry.  Parts of receptors may be more accessible to one part of a stimulating chemical than to other parts of the same chemical.  Perhaps some parts of the opiate receptor are shielded by other receptor structures.  Or perhaps more lipid-soluble drugs have access to parts of the receptor that more water-soluble drugs do not.
I suspect that over time, we will develop protocols for dealing with post-operative pain in buprenorphine patients.
Thanks again, Dr, for your comments.

Thanksgiving and Suboxone… Is My Surgeon A Turkey?

Thanks to Mike for this question:
I’m having surgery the day before Thanksgiving.I take 24-32mg a day for the past year,and I’m a little worried about surgery.I told my surgeon I take suboxone and I’m a recovering addict,and I don’t take pain medication. But he told me he will treat me as a normal patient,and with that percribed me 60 percocets. I went to my pharmacist and talked to her about it,she called the doctor and he called me back to his ofice, I told him I was concerned about the 60 percocets he gave me,his reponse was again “I’m going to treat you as a normal patient” what ever that means? Anyway I did’nt fill original perscription,so he gave me a new one, 40 percocets,hmmmm. Anyway NO one in my family know’s I take suboxone,and they also don’t think I have a perscription for painkillers,my problem(other then lying about the two medications) is the day of surgery,and the fact that I have a doctor who does’nt understand addiction.I know I will be given fentynol,I stopped taking the suboxone two days agos’which will give me 3 days to get the suboxone out of my system,will that be enough time,considering my daily dose?
My Response:
That is a fairly high daily dose of Suboxone;  R-B sent out a mailing a few months ago setting (or ‘resetting’) their recommended dose range, taking into account the current problems with diversion of Suboxone onto the street.  I often say to patients that ‘the main problem with taking such a high dose, other than the waste of money, is that if you ever needed surgery it would be very difficult to overcome the block from that much buprenorphine’.  So I am glad that you will be off the Suboxone for several days.  Even after 3 days you will still have a significant amount of Suboxone;  the half-life is about three days, so if you took your last dose of 32 mg three days ago, you would have the same amount of buprenorphine in your body as a person who took 16 mg this morning.
I have one patient who had emergency surgery a few hours after her morning dose of 16 mg of Subutex (she had a C-Section).  The surgery went fine– she had a spinal, but as I have mentioned here before there is no significant problem with anesthesia, whether it be by epidural, spinal, or general.  For procedures on the lower extremities or abdomen an epidural is ideal, as then the catheter can be used for providing analgesia post-op by infusing a low concentration of bupivicaine or another local anesthetic. If an epidural isn’t an option, the main problem with surgery on Suboxone is controlling the post-op pain.  My patient with the C-Section had to go to the ICU– they weren’t comfortable on the ward–to get morphine every couple hours, in doses as high as 30+ mg.
I’m a little confused, Michael, by the conversation between you and your surgeon. I’m not certain what you meant when you went back and said you were concerned about the 60 percocets– were you concerned that there were so many, or that there weren’t enough? 60 percocets may be too few or too many, depending on the nature of the surgery and the size of the percocets.  One thing that isn’t relevant, that many people get confused over, is your dose of Suboxone– at least from the perspective of your tolerance.  Because of the ceiling effect, your tolerance will by the same, whether you take 8 mg Suboxone or 32 mg Suboxone.  Of course, the residual Suboxone in your system will be higher from the higher dose, and so you will need more post-op medication taking that into account.
First, though, I’d like to point out something that is the result of ‘stigma’.  Your surgeon said and did something that is unfortunately quite common when he said he would ‘treat you like a normal patient’.  On the surface, and from the surgeon’s perspective, that sounds quite big of him;  he isn’t going to punish you for being a ‘scum-of-the-earth-drug-addict’– he is going to act as if you are a genuine human being!  Gee, thanks, Doc!  I admit I don’t know what is in his head– is he thinking ‘I won’t discriminate against him’, or is he thinking, ‘I’m not going to fall for some addict story about increased tolerance!’  I don’t know which– but in either case, he is making a mistake:  You’re NOT a normal patient!  If you were three years old, would he treat you like a ‘normal adult patient’?  If you had severe respiratory disease or a head injury would he treat you ‘like a normal patient’?  And if you had cancer, and had been taking high-dose narcotics for six months, would he treat you like a ‘normal patient’?  Here is where I should say: THIS REALLY MAKES ME SICK!!
You have two reasons to need higher doses of pain medications post-op: residual buprenorphine in your system, and high tolerance.  Even if the buprenorphine is completely gone, your tolerance is such that it will take about 60 mg of oxycodone every 6-8 hours just to ‘break even’!  If the percocet have 10 mg of oxycodone in them (some have as low as 5 mg), it will take about 20 percocet per day just to prevent withdrawal! (60 mg oxycodone or 6 tabs every 6-8 hours= 18 or 20 tabs per day).  When I am taking over for post-op pain management in a person on Suboxone, I usually start at about 30 mg of oxycodone every 4-6 hours.  I keep the acetominophen out of it i.e. I don’t use percocet because you end up taking enough to harm the liver when you are taking that many percocet.  I will treat the pain with extra opiates for as long as the surgeon would generally use narcotics– that is the only way that I treat people as if they are ‘normal’.  I know that the person will need higher doses, but I don’t see a reason why the patient would need an opiate for a longer period of time.  Sometimes the patient has a hard time giving up the opiate– there is that quick rekindling of the long-lost love affair… but I say ‘tough- get over it’ and get the person back on Suboxone!
Don’t forget– to go back on Suboxone you will need to have time between the last dose of opiate agonist and taking the Suboxone.  I like 24 hours– although you may get away with less time.
Two final comments.  First, consider decreasing your daily dose of Suboxone.  If taken correctly, the opiate effects of Suboxone hit the ceiling at about 4 mg per day– so even 16 mg is overkill.  We don’t know of any significant harmful effects of chronic buprenorphine treatment, but in general, doses of any medication should be kept as low as possible.  Plus it would be cheaper for you or for your insurer!
The final comment is that even recovering opiate addicts will occasionally need pain medications.  You mentioned that you ‘don’t take pain pills’– there are times when you will simply have to take them.  People who attend 12-step meetings take them as well, while attempting to minimize their use as much as possible.  Use of pain pills that are appropriately prescribed during an honest encounter with a doctor is not considered a break in sobriety, so you don’t have to start counting clean time from scratch again!  Many people find it helpful to put a trusted person in charge of the pain medications– someone with the guts to say ‘no’ to you after the opiates have done their thing to your mind, and you are begging for more, convinced that your pain is the ‘worst pain in the whole wide world’!  Picking the person to manage your meds is similar to an AA picking a sponsor;  there is a desire to pick someone who is a pushover, but you know down deep that you are safer with someone who is a bit tough.
Michael, I wish you the best with your surgery.  I hope you are able to at least nibble on the Turkey on Thursday.
SD