Ten Gripes of Buprenorphine Doctors

I recently gave a lecture to medical students about opioid dependence and medication assisted treatment using buprenorphine, methadone, or naltrexone. I was happy to see their interest in the topic, in contrast to the utter lack of interest in learning about buprenorphine shown by practicing physicians. In case someone from the latter group comes across this page, I’ll list a few things to do or to avoid when caring for someone on buprenorphine (e.g. Suboxone).

1. Buprenorphine does NOT treat acute pain, so don’t assume that it will. Patients are fully tolerant to the mu-opioid effects of buprenorphine, so they do not walk around in a state of constant analgesia. Acute pain that you would typically treat with opioids should be treated with opioids in buprenorphine patients. Patients on buprenorphine need higher doses of agonist, usually 2-3 times greater than other patients. Reduce risk of overuse/overdose by providing multiple scripts with ‘fill after’ dates. For example if someone needs opioid analgesia for 6 days, use three prescriptions that each cover two days, each with the notation ‘fill on or after’ the date each will be needed.

2. Don’t say ‘since you’re an opioid addict I can’t give you anything’. There are ways to provide analgesia safely. If you do not provide analgesia when indicated, your patient will only crave opioids more, and may seek out illicit opioids for relief. Unfortunately nobody will criticize you for leaving your patient in pain, but they should!

3. Don’t blame the lack of pain control on laws that don’t exist, for example “I’d like to help you but the law won’t let me.” Patients deserve honesty, even when the truth makes us uncomfortable. We get paid ‘the big bucks’ for tolerating the discomfort that sometimes comes from frank discussions with our patients.

4. Don’t assume your patient can or cannot control pain medications. If a patient has been stable on buprenorphine for years, he/she may have a partner or family member who you can trust to control pain medications. Some patients stable on buprenorphine can control agonists used for acute pain, but I wouldn’t stake my life, or theirs, on that ability. A useful compromise is to prescribe enough pain medication to cover 1-2 days of analgesia on each of several prescriptions, each with a ‘fill after’ date, to reduce the amount of agonist controlled by the patient at one time.

5. Don’t tell your patients that ‘opioids don’t work for chronic pain.’ I see stories on such great medical sources as the ‘Huffington Post’ explaining that ‘opioids never help chronic pain’. In reality, your patients know that opioids DO treat chronic pain, so they will consider you a liar or an idiot if you clam they don’t. The challenge is explaining the risk/reward equation to your patients, and explaining why treating chronic pain with opioids often leads to greater problems, as the risk/benefit equation is changed by tolerance.

6. I know this will cause heads to explode, but don’t assume that chronic pain is always less severe than acute pain. What if your patient’s chronic pain is worse than the typical pain after cholecystectomy or ACL repair? Most doctors would gasp at the idea of recovering from major surgery without opioids. What if the pain from failed back syndrome is worse?! I have had a few patients who, I’m certain, experience a great deal of suffering, and have gone so far as to have brain or spinal cord implants to get relief. I’m not arguing that we treat chronic pain in the same way as acute pain. But we shouldn’t jump to the conclusion that chronic pain isn’t severe enough to warrant opioids in order to dismiss those complaints more easily.

7. Don’t tell your patient to stop taking buprenorphine unless you’ve talked with the doctor who is prescribing that medication, and realize that the doctor you are calling knows more about buprenorphine and addiction than you do.

8. Don’t ask patients ‘how long are you going to take that stuff’ or criticize patients’ use of buprenorphine medications. Likewise psychiatrists shouldn’t tell patients scheduled for knee arthroscopy that the procedure is controversial, or talk patients out of hernia surgery.

9. Don’t assume that the doctor prescribing buprenorphine knows what YOU are doing. Too often patients will tell me about surgery that they failed to discuss in advance, even calling about pain hours after getting home from a procedure they failed to mention. Some people seem to believe that doctors regularly collaborate on their care, even though the opposite is closer to the truth.

10. Don’t assume that unusual or atypical symptoms come fromo buprenorphine. One truism of medicine is that doctors tend to blame unexplained symptoms on whatever medication they know the least about. Fevers of unknown origin, mental status changes, or double vision are not ‘from the buprenorphine!’

Those are the gripes at the top of my list. Did I miss one of yours? Or for patients, have you suffered from breakdowns in the system?

Addendum: 11. When treating post-surgical pain in buprenorphine patients, choose one opioid and stick with it. What often happens is that doctors will use one opioid, say morphine… and when nurses call a few hours later to say the patient is still screaming, they change to a different opioid, then another after that. As a result, the patient is placed on insufficient doses of several opioids, rather than an adequate dose of one medication.

There are two critical issues in treating such patients effectively. First, providing pain relief comes down to competition at the mu receptor. A certain concentration of agonist in the brain and spinal fluid will out-compete buprenorphine and provide analgesia. You cannot get there by adding other opioids together. If you use oxycodone for an hour and then change to dilaudid, you are starting over. Instead, choose one drug, preferably something that can be given intravenously, and stick with it. Morphine is not a good option btw, because of the low potency and histamine releasing properties of that drug.

Second, remember that analgesia and respiratory depression travel together, both mediated by the mu receptor. Anesthesiologists know this principle well… opioid medication can be titrated to respiratory rate, providing that the medication is given IM or IV. If a patient is breathing 28 times per minute, he/she is in pain. If the patient is breathing 6 times per minute, pain is not a problem, and the patient should be monitored for respiratory depression and possible overdose. When treating pain, doctors should aim for a respiratory rate of 14-18 breaths per minute, making sure that the medication is actually getting into the bloodstream (the risk comes when patients are given SQ injections or oral doses of narcotic that enter the bloodstream later, causing toxic blood levels).

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.

Uncoupling of analgesia, tolerance, and euphoria from mu-agonists using buprenorphine

I presented this topic at the Atlanta meeting of ASAM a couple weeks ago.  There are too many slides, but the historical stuff was just too fascinating to leave out.  I wanted to demonstrate,  by lining it up on the side, how time has compressed the most critical discoveries to a very short period of time.  In other words, it wasn’t until thousands of years of opium use that the general concept of endorphines and opioid receptors came along.  We can only hope that similar understandings of the biological basis of tolerance and withdrawal will be comparatively soon.
My study shows something truly fascinating– that a partial agonist seems to anchor tolerance at a lower level, still allowing for potent analgesia, but preventing euphoria and dose escalation.  I have used this combination in people with very major surgeries, that are known to be quite painful– i.e. knee and hip replacements, dental surgeries, gallbladder surgery, and median sternotomy.

Suboxone, Pregnancy, C-Section, and Surgery

A recent message from a reader:
What would be the ideal care-plan for the pt taking 24mg/dayof Subutex who is going in for c section? I would like to show the response tomy OB, so if there is any way, please be specific as to any tapering or substituting of another low-dose narcotic before surgery, the best med for pain control in recovery and while still in hospital, up to discharge and the best PO med course for home. I would be so appreciative and you’d really help ease my fears.
Thank you 🙂
My Answer:
I receive this question often, and I am confident in my ability to provide education about the issue.  I have to point out that I can’t act as your doctor and give medical advice — but I’ll share my experienceafter having a number of patients on buprenorphine (i.e. Suboxone) go through a wide range of surgeries.
You can share with your doctor that I’m Board Certified in Anesthesiology, and I worked in Ors and pain clinics for ten years before leaving the field for psychiatry residency.  Your doctor is more likely to believe me, knowing I have experience in that area.
I will send you a couple references about this topic, and I’ll also send my ‘Users Guide to Suboxone’. The articles provide support for the treatment I’m about to describe.
Did I mention that anyone reading this MUST use the information only to spark a discussion with his/her own doctor? Do NOT use this information on your own; doing so would be quite dangerous—not to mention illegal.
A couple basics first…  The anesthetic for the surgery (in this case, a C-section) should be conducted the same as with any other patient.  Spinals and epidurals work fine.  Local anesthetics are not affected by Suboxone, and the spinal narcotics sometimes used play only a small role in analgesia during surgery, being more important for post-op pain.
Likewise, a general anesthetic in your case would not be affected by buprenorphine, since a narcotic-based anesthetic is not appropriate for a c-section.  So we are really talking about post-op pain in this discussion.
There are two major issues when dealing with post-op or other acute pain in people on Suboxone or buprenorphine (the two medications are clinically identical;  in each case, buprenorphine is the only issue, since naloxone is NOT active orally or sublingually).
The first issue is that buprenorphine is a partial agonist that acts as an antagonist at opioid receptors after surgery in the presence of narcotic pain medication.  Buprenorphine is a
high-affinity, long-acting medication that is VERY effective at blocking the mu opioid receptor. To deal with this first issue, you need to get your blood level of buprenorphine lower.  The buprenorphine half-life is over 3 days, so it takes a week or more to make significant reductions in the blood level of buprenorphine in preparation for surgery.  It is possible to treat your pain on, say, 16 mg of buprenorphine per day– but difficult, requiring very high doses of oxycodone to out-compete the buprenorphine. I have never tried treating pain in a person on 24 mg per day, but I would expect it to be even more difficult than at 16 mg per day.
I tell patients having planned surgery to taper down their dose of buprenorphine a couple weeks in advance.   For someone having a C-section there is a second reason, beyond pain control, to lower the dose of buprenorphine, as doing so will also lessen the chance that the baby will have withdrawal (although I encourage people to avoid getting worked up over that
issue.  Studies show that ‘neonatal abstinence syndrome’ from buprenorphine is much less severe than from other opioids like heroin or methadone).
I have patients taper down to 8 mg per day or less by the time of the surgery–ideally by a week before the surgery.  In my experience, most people don’t notice significant discomfort if they reduce by a quarter tab every week or two (when people stop buprenorphine, most of the withdrawal occurs when tapering off the final 2-4 mg per day).  The goal is to get to 8 mg per day (or less) so that mu opioid receptors can be activated by opioid agonists like oxycodone or fentanyl.
****  It would be a mistake to try to treat your pain using ‘just buprenorphine’.  Some docs apparently do that, as I occasionally receive messages from angry patients who were told they would be fine, who then go through horrendous experiences and write to me, asking me to help them sue their doctors.  People on Suboxone or similar doses of buprenorphine are
FULLY TOLERANT to the effects of buprenorphine, and because of the ceiling effect, higher doses of buprenorphine will provide NO significant pain relief.
As for the second issue, even if we could magically remove all of the buprenorphine in a patient’s system on the day of surgery (we can’t), the person would still have a high opioid tolerance—and so would require high doses of opioids to treat pain.  There is debate over the exact tolerance, but in my experience people on buprenorphine have a tolerance similar to someone taking 60 mg of oxycodone per day, or 40 mg of methadone per day.  That means that even if we could remove all of the buprenorphine, it takes 60 mg of oxycodone (or equivalent) just to break even, before providing pain relief.  Since buprenorphine will be in the system, it takes more than 60 mg– but 60 mg is the starting point.
With that in mind, I generally try to give people the equivalent of 60 mg of oxycodone per day, and provide more oxycodone ‘as needed’.  One way is to give Oxycontin, 20 mg three times per day, and then use oxycodone 15 mg every 4 hours as needed.  Another way is to avoid the Oxycontin, and give oxycodone, 15-30 mg every 4 hours as needed.
**** Oxycodone is a 4 hour medication.  Some doctors make the mistake of thinking that since they are giving higher doses, they can give it less often. Again, their patients write to me afterward to complain.  Oxycodone is metabolized at the same, fast rate in people on buprenorphine as in everybody else, and has little effect beyond 4 hours.
**** Some docs fear respiratory depression from using high doses of opioids, and would rather just let the person suffer than carefully think through the issue.  I’ve even heard about docs telling patients ‘there is nothing that can be done for your pain’.  That is nonsense; pain relief CAN be provided, but it takes high doses of narcotic to do so, and THAT requires some extra planning.  If they need to put you in the ICU to feel comfortable, so be it– you deserve pain relief.
For doctors:  because of the long half-life of buprenorphine, ‘renarcotization’ is not an issue.  (that situation can occur with short-acting antagonists like naloxone, when a patient receives long-acting pain medication… and then the blocker wears off, leaving the patient vulnerable to respiratory depression).   Buprenorphine easily outlasts any agonist, so a patient is not going to suddenly overdose.  In fact, people on buprenorphine are protected to some extent from overdose; deaths on Suboxone occur when a person with a low or no opioid tolerance takes Suboxone, usually combined with a second respiratory depressant like alprazolam.  People on buprenorphine usually report getting pain relief from 15-30 mg of oxycodone,
but not ‘feeling’ the drug in any other way.  They feel no euphoria or sedation– but they get pain relief. I’ve written about the benefits of the combination for treating severe chronic pain but that’s another issue….
Typically, XXXXXXX, I tell my patients to taper to one tab of buprenorphine or Suboxone per day by a week before surgery.  Starting the day before surgery, I have them take a half tab of buprenorphine or Suboxone per day– and continue that on the day of surgery, and throughout the post-op period.  Why continue it?  Because with the long half-life, it will be there anyway– and I feel better having some idea how MUCH is there.  There are benefits to continuing it as well, such as preventing euphoria from opioid agonists, and making it easier to restart the full dose of buprenorphine later– without the need to go through 24 hours of withdrawal to avoid precipitated withdrawal.
I would have the surgeons do the surgery as they always do, using general, spinal, or epidural.  For post-op, I usually recommend using PCA (patient controlled analgesia) with fentanyl; there are some anecdotal reports that fentanyl competes more effectively with buprenorphine than morphine (which would make sense, since fentanyl has much higher affinity).  I suggest that they forget numbers, and set the PCA for at least twice what they normally would use, pay close attention to your respiratory rate, pulse-ox, and PAIN, and increase the dose QUICKLY if necessary.
As soon as you are taking oral meds, things become much easier.  I usually recommend the medications listed above– i.e. 15-30 mg of oxycodone every 4 hours.  I sometimes use a ‘basal narcotic’ like oxycodone, and dose on top of that as mentioned above.
When you no longer need opioid pain relief, stop taking oxycodone for at least a few hours, and then resume your full dose of buprenorphine.  NOTE– I have not had a patient get precipitated withdrawal, provided they continue at least 4 mg of buprenorphine every day throughout the post-op period.  But I cannot guarantee that it won’t happen.
The safest thing is to stop the oxycodone for longer than 4 hours– for as long as possible, until you actually feel withdrawal– and THEN restart buprenorphine.
I have to stop at this point– I will send those articles when I’m at work tomorrow.  Good luck with your new baby!
JJ
FYI:  E-mail me for a free copy of my ‘User’s Guide to Suboxone’ and for the reference described above.

I'm On Suboxone; Can I Have Surgery?

I recently resumed writing for the expert forum on addiction at MedHelp.Org. One result of writing for MedHelp is that I receive a number of e-mails from people with questions about specific issues related to buprenorphine. The most common questions are from people on buprenorphine undergoing surgery, asking about the safety of anesthesia and about postoperative pain control.
There are very significant problems with medical coverage for patients on buprenorphine undergoing surgery. Patients on buprenorphine will occasionally need surgery, and in such cases there are often no doctors willing and/or competent to manage postoperative pain. Psychiatrists, frankly, have little knowledge or experience in this area. Before psychiatry residency, medical school graduates generally complete a medical internship that provides little or no training in critical care or surgery. Making matters even worse, the medical students who go into psychiatry tend to be those who have the least interest in the surgical specialties.
And then there are surgeons. Where psychiatrists lack courage to provide effective pain relief for addicts, surgeons simply lack interest or concern. Surgeons enjoy being in the operating room, cutting things apart and sewing things together. The last thing they want to do is have a heart-to-heart talk about someone’s addiction to pain pills. To a surgeon’s way of thinking, addiction doesn’t even exist. You can’t cut it off or sew it on, so why even talk about it?
Hopefully, those of you who take buprenorphine will slip this article under the door of your psychiatrist to drop a hit about this problem. I cannot provide medical recommendations for people who I do not know, but I will at least provide some general information so that readers of my blog will know when they are being fed a line of nonsense.
Speaking of nonsense, the silliest and most potentially harmful advice that I hear about in e-mails is that buprenorphine will cover a person’s postoperative pain; that the person should simply take his/her normal dose of Suboxone and everything will be fine. Nonsense! People taking buprenorphine quickly become tolerant to the pain-relieving properties of buprenorphine, and therefore will not get adequate pain relief from buprenorphine for anything but the most minor surgical procedures. Buprenorphine has complex actions at opioid receptors, including partial agonism at mu receptors and mixed effects at kappa opioid receptors. The actions at kappa receptors are less subject to tolerance and provide some long-term effects on mood and analgesia, but these effects are not even close to what is required to cover postoperative pain.
There are several articles that have been published that describe various approaches for treating postoperative pain in patients on buprenorphine. I cannot post the articles here because of copyrights, but the general recommendation in the literature for treating post-op pain is to reduce the daily dose of buprenorphine starting several days before the surgery, and to use potent opioid agonists in addition to buprenorphine. Another option is to stop buprenorphine completely before surgery. But buprenorphine has a long half-life, and must be stopped for a week or more in order to significantly lower the level of buprenorphine in the body.
It is important to understand that there are two things that get in the way of pain relief in patients on buprenorphine; the antagonist actions of buprenorphine at the mu receptor, and the patient’s high tolerance to opioid agonists. Even if buprenorphine is stopped a week or two in advance of surgery, the person still has a high tolerance to opioids, and still requires significant doses of opioid agonists for adequate post-operative pain control. And if buprenorphine is stopped completely, the person must go through a period of withdrawal before eventually restarting buprenorphine in order to avoid precipitated withdrawal.
I have found it easiest to keep the person on a small dose of buprenorphine, perhaps 4 mg per day, throughout the entire operative period, until postoperative opioids are no longer needed. I’ve had good success treating post-operative pain with high doses of oxycodone while continuing buprenorphine, even after major surgeries. Interestingly, patients report good pain relief but the complete absence of the euphoria that they used to get from opioids. At the point after surgery when opioid agonists are no longer necessary, patients simply stop the agonists and resume their full dose of buprenorphine.
Whether or not buprenorphine is discontinued, high doses of opioid agonists are required to provide adequate pain relief for major surgery. An oxycodone equivalence of about 60 mg per day is required just to ‘break even’ with the tolerance of a typical person on buprenorphine maintenance. You can understand, then, why psychiatrists are wary of treating postoperative pain. Such high doses of oxycodone could easily cause fatal overdose in patients not taking buprenorphine. I am board certified in anesthesiology, but even I get nervous in such situations. But what is the alternative? I have had patients who required coronary bypass, hysterectomy, and total knee replacement, as well as minor surgeries. Dental work in particular is quite common in patients with a history of addiction. Should people on buprenorphine simply go without the necessary procedures that other people are allowed to have?
If psychiatrists or surgeons are unwilling to provide adequate postoperative analgesia for patients to take as outpatients, patients should allowed to stay in the hospital, even the intensive care unit, if that is what it takes for the doctor to feel safe providing adequate analgesia. Surgeons should provide adequate care, even if they have to fill out paperwork and battle insurers to obtain the necessary coverage for hospitalization. They would do the same for patients with brittle diabetes who need close monitoring following surgery. Opioid addicts are people too!
As for general anesthesia, buprenorphine does not pose significant problems, provided that the anesthesiologist is aware that the patient takes buprenorphine and has a high opioid tolerance. Opioids are often used during anesthesia to blunt changes in blood pressure and heart rate, and larger doses of opioids would be required for people taking buprenorphine. The amnesia component of an anesthetic is generally provided by medications not blocked by buprenorphine, such as anesthetic vapors or benzodiazepines.
Another reason that anesthesiologists must be made aware if a patient is taking buprenorphine is so that sufficient opioids are ‘on board’ when the patient awakes. As patients emerge from anesthesia, anesthesiologists often use respiratory rate to gauge whether sufficient doses of narcotics have been provided to cover postoperative pain. Without the knowledge that a patient is on buprenorphine, the anesthesiologist may be confused by the patient’s lack of response to narcotics, causing the anesthesiologist to give too little pain medication—meaning that the patient will awake with considerable pain.
Medications with combined actions (such as tramadol and the newer agent Nucynta) or of little value for post-operative pain control. These medications have actions at mu opioid receptors that are blocked by, and cross-tolerant with, buprenorphine– completely nullifying that component of their action. The other component of their action is through effects on serotonin or norepinephrine pathways, and these actions are insignificant for post-surgical pain. Because of mu receptor tolerance, Nucynta essentially becomes as useful for treating post-op pain as Cymbalta— i.e. worthless!
I must stress that everything I have written here is intended to serve as a basis for discussion between patients and their doctors. Every case has unique variables that must be taken into account, and so my comments must not be taken as medical recommendations or advice. Taking high doses of opioid agonists can be dangerous, particularly in combination with other respiratory depressants.
One final comment… I recently received letters from two different health insurers about ‘buprenorphine policies’ citing situations where Suboxone would not be covered. These situations have included cases where patients are prescribed opioid agonists. I want to point out that there are times when patients on buprenorphine require surgery, and every patient undergoing surgery deserves adequate pain control. There are also patients on buprenorphine maintenance who have chronic pain; pain that in some cases justifies the relief afforded by opioid agonists. I hope that those with the power to influence policy, including Reckitt-Benckiser, the American Society for Addiction Medicine, NIDA, and SAMHSA, will direct attention to this important gap in medical coverage.

Medical bias against addiction

I haven’t gone anywhere in case you’re wondering… but I recently started writing a blog on Psych Central, called ‘an epidemic of addiction.’   Please add it to your reading list!  This is my favorite time of year and the time I am most likely going to be outdoors, so watch for posts to pick up a bit as things get colder outside.
I’m probably in the wrong state of mind to be blogging, so consider this more along the line of venting.  I had an encounter with a local physician a couple days ago that left me shaing my head–  I have a solo practice so I have forgotten just how misguided medicine can sometimes be.  I was asked to speak with an orthopedist for a patient who takes buprenorphine, who was having major knee surgery.  The orthopod started the discussion by saying that he is angry that the patient didn’t say at their first meeting that he takes Suboxone– like it should have been spelled out on his forehead, to make certain that he didn’t give the patient some undeserved pat on the back or some measure of kindness.  I explained that people on buprenorphine find often find that they are treated differently by (ahem) those doctors out there who (AHEM) pre-judge people…  And the ortho guy said ‘well, for good reason!’  As I remember the encounter I’m having visions of the song ‘KILL THE BEAST!’ from Beauty and the Beast– I’m sure this particular doc wishes we ALL would just go away…

Is addiction treated like a disease?

Where was I?  Oh yes–  the doc then explained to me just how hard it is for him to treat people on Suboxone.  He explained how the ‘therapeutic window’ is narrower– meaning that the ratio of the dose that treats to the dose that kills is larger.  I tried to explain that it ISN’T– the entire window is HIGHER, but not NARROWER.  You all know that, of course– on buprenorphine your tolerance goes up, and it takes a much larger dose of opioid to get pain relief, and a much, much, much larger dose of opioid to cause death.  I tried to explain that this is not rocket science;  I would taper the person off buprenorphine ahead of time (I usually tell people to take 4 mg of buprenorphine per day for a week before the surgery, then skip it entirely on the day of surgery), and he could simply treat the person as he would anyone who is tolerant to about 60 mg of oxycodone per day.  I still cannot believe the response from him–that ‘nobody around here takes that much oxycodone’– that those are ‘big city problems’ and that there just aren’t people doing that around here. 
Wow. 
He told me that he doesn’t like giving pain pills to ‘these people’ (he knows, by the way, that I am an opioid addict).  Never mind that he is going to be doing a ‘total knee’, where the ends of the femur and tibia are sawed off and replaced with metal pieces.  I explained that proper treatment is to provide a basal amount of narcotic, and then use a larger than normal PCA (patient controlled analgesia) deamand dose.  I explained that fentanyl may work better according to some reports, but he said ‘I never use fentanyl.’  So I explained that he could use morphine, but that it would take at least 5 – 10 mg IV to have ANY effect on pain.  He said that he would never give that much– that he would give less than usual, if anything.
At some point he mentioned that it bothered him that the patient has taken buprenorphine for 8 months– that it bothered him to ‘think that there are people out there walking around on that stuff.’  I told him that in some states, the more progressive and intelligent licensing boards are recognizing that patents on buprenorphine are not impaired, and are treating them like regular people– to which he replied ‘then why don’t we just give alcoholic pilots a 12-pack and let them fly?!’
Wow.  I had a range of feelings after the discussion.  The first thing I did was contact the patient and strongly recommend that he seek surgery elsewhere.  The guy I am talking about is good enough at sawing bones, but is clearly an idiot when it comes to thinking through medical challenges– and my patient deserves to know that.  In a perfect world, someone would recognize that doctors like this one have no business working in the field of medicine.  I used to work with this doc when I was an anesthesiologist and I knew that he was bone-headed (pun intended!), but I had forgotten just how nasty and judgmental he could be.  I am tempted to post his name, but I won’t — it would only bring me even more headaches than I already create for myself!  But if anyone is having orthopedic surgery in Northeast WI, feel free to send me an e-mail and ask.
The main thing I’d like to say though is that I am sorry that the medical profession has those types of people among its memebers.  Those of you who feel like you are suddenly being judged, when your doc finds out that you have struggled with addiction– you are probably NOT going crazy.  Ignorance is alive and well, and the day when addiction is treated like other diseases is still a long ways off.  And that is a real shame.

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.

Fentanyl patch for post-op pain, on Suboxone?

I’m in a bad mood tonight– squabbling with my 13-y-o daughter will do that to me– so I’m going to cheat and copy an e-mail that I recently sent to a reader.  She takes Suboxone and will be having surgery;  she did everything correctly, tapering her dose and then stopping the Suboxone for a few days before surgery.  Ideally her addiction doc or her surgeon would prescribe her a large dose of oxycodone to treat the post-op pain, but instead she was told that she is already treated for pain from being on the Suboxone, so she doesn’t need anything more.  After her appropriate objection, he told her that he would recommend that the surgeon prescribe– of all things– fentanyl patches.  Never mind that fentanyl patches have a ‘Black Box Warning’ by the FDA, that they are contra-indicated for treatment of post-op pain!.
As I mention in the e-mail, fentanyl was my ‘drug of choice’– it is a staple of the anesthesiologist’s ‘sleep kit’.  I have had a number of patients who abused fentanyl;  one person was drying and smoking the stuff that she scraped from the patches (it gets even more disgusting– she collected used patches from the backs of old people in nursing homes, pooling them together to  get enough used-up resin to get high (the patches are sometimes put on the mid-back area of demented, elderly patients so they don’t peel them off and throw them away).  I wouldn’t normally write about something that would provide a ‘tip’ about how to use– please continue reading.  She smoked this dried mess, and the vapors from whatever chemicals it consisted of trashed her lungs.  She developed ARDS (Adult Respiratory Distress Syndrome) and almost died, eventually leaving the ICU with permanent pulmonary problems (try saying THAT three times real fast!).  So don’t smoke that garbage.
OK… my message, filled with righteous indignation:
Yes, just to validate what you already know, you DO need extra opiate to compensate for pain—people on Suboxone are on that level of opiate as their ‘baseline’, and so of course you need something more potent when pain control is needed!  I wonder—does your Suboxone think that everyone on the medication is covered for all their pain control needs?  Is there ANYTHING he would consider providing pain medication for?!  I worry about this type of situation, since the people who end up treating addiction and prescribing Suboxone are not the same docs who have experience in prescribing pain medication.

I like your idea of letting the surgeon see the recommendation and then asking for something a bit less potent.  I don’t think the fentanyl patch would kill you (how reassuring that must sound!), and there are things you can do to make it safer–  there actually have been deaths associated with the patch, and I think there might even be a warning that comes with it now that it is not to be used for post-op pain—but by understanding some things about the patch you can make it a bit ‘less inappropriate’.  The first thing is to never cut the patch in an attempt to make it less potent.  Different brands have different things inside—some have gels, some have a semi-solid matrix, some have liquid—and some are safe to cut, but most aren’t, so just don’t do it.  The risk is when it is cut, the fentanyl leaks out and gets absorbed through the skin at a much faster rate than 100 micrograms/hour, leading to respiratory arrest.  The second important thing is to avoid heating the patch when it is against your skin, as that will increase skin blood flow which will cause greater absorption of fentanyl… again leading to respiratory arrest.

Fentanyl is an interesting drug—so interesting that I made it my drug of choice during my days as an anesthesiologist!  I was ‘outted’ (is that the right spelling?) by Men’s Health magazine—Google ‘men’s health’ and ‘junig’ and you will find the story–  and in the article they suggest that anesthesiologists breathe vaporized fentanyl that leaves the body of the unconscious patient through the opened abdomen, and they cite a study that found plasma levels of fentanyl in anesthesiologists just from a day’s work.  The guy who interviewed me for the story, Chris McDougall, suggested that this is why anesthesiologists become addicted to opiates.  I told him I thought the idea was silly—but he wrote about it anyway.

In small IV doses, fentanyl (which is a fat-soluble molecule) hits the brain and then ‘redistributes’ into the fat compartments of the body, so that the level in the bloodstream and at receptors rapidly decreases.  As you give more and more fentanyl, eventually the fat compartments become filled with fentanyl, and there is no place for it to ‘redistribute’ to.  At that point the blood level builds up, and is any decrease is dependent on breakdown at the liver—a slow process.  So in some cardiac anesthetics, where very large doses of fentanyl are given, the patient remains on a ventilator for up to 24 hours and sometimes even longer.

Wearing a fentanyl patch has effects similar to being on an IV infusion of fentanyl.  Initially, the fentanyl enters the blood and at the same time leaves the blood by entering fat compartments of the body.  After a few days, the fat compartments become saturated and there is nowhere for the fentanyl to go… and the blood level therefore rises.  The deaths from fentanyl patches often occurred after several days, because of this phenomenon.  Overdose from opiates occurs from respiratory depression, and the degree of depression can be measured by the respiratory rate.  I should add that benzos like Valium or Xanax greatly increase the respiratory depression from opiates.  You can help reduce the risk of overdose by having someone count your respirations when you are at rest or sleeping—you can’t count your own because you will change the rate if you pay attention to it!  The way doctors do it during exams (I am giving away a secret here!) is to hold the patient’s wrist and pretend they are counting the heart rate, and watch or listen to the patient’s breathing and count that instead, while watching the second hand on their watch.  Anyway…  if someone follows your respiratory rate while you are resting or sleeping, a normal rate is about 16;  the rate of a person in pain is usually above 24;  a person who is getting too much narcotic will have a rate of 12, then 10, then 8, then 6…  and after that they might just stop.  People who snore are at greater risk, because as the drive to breathe goes down, they are more and more likely to stop moving past the obstruction.  From a practical standpoint, if your respiratory rate drops below 12, I would suggest removing the patch, and keeping if off until you are alert and the pain has returned.  There will be a lag time with patches—it takes an hour or two for them to start working, and after removing them there will still be some absorption of fentanyl from the skin for an hour or two.

I had better send this off.  Again, I’m sorry your doc isn’t more enlightened.  Be careful out there… and keep us up on how things go!

SD

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.