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.

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

Anesthesia and Suboxone, revisited…

Important enough to move to the front page:

HELP!!!!! I’m so confused. I am having surgery on Friday and have been told to stop suboxone(8mg twice a day) 24hrs prior. I’ve taken it for a little over 2 years and it has really changed my life-for the good. Now I’m scared after reading everything. I do not want it to interfere with anesthesia. Post op I had planned to go back on suboxone. The surgeon is implanting a pump that delivers xylocaine directly to the site of the surgery so I feel certain that will be a tremendous help I just don’t want to “wake up”while under general anesthesia(I’ve heard horror stories about that happening).
Someone please reply ASAP now I can’t sleep!
Thanks so much for reading this
Carrie

Reply:

Carrie, don’t worry. I am a Board Certified Anesthesiologist (I took the Boards back when they lasted for life! good for me!). It would take an idiot anesthesiologist for Suboxone to interfere with the anesthetic! Suboxone (buprenorphine) blocks only the narcotic–nothing else. During surgery there are different ways to give an anesthetic, but the ‘amnesia’ does NOT rely on opiates. In fact, it is possible to provide deep anesthesia with no opiates at all, using only the ‘inhaled’ anesthetics (that does NOT mean that YOU inhale them while awake– you are put ‘out’ using propofol, which is NOT blocked by Suboxone, and then a gas is given through the endotracheal tube or mask after you are unconscious). You can also do an anesthetic using a propofol infusion– again, not blocked in any way by Suboxone. It is possible to do a ‘narcotic-based anesthetic’, but in that case the amnesia usually comes from a low amount of gas, or a benzo, or some propofol– none of which are blocked by Suboxone. Let the anesthesiologist know you are on buprenorphine, and if he looks confused tell him it is ‘a partial agonist at the mu receptor’ and he will undertand! If he acts like you are causing him a tough day, he is only being a jerk– because Suboxone is NOT a problem.


The time it IS an issue is post-op, because that is when you need a narcotic– for pain control. Here is what I usually recommend for patients who have surgery: if you are on 16 mg of Suboxone per day, try to stop it two or three days before the surgery– that way there will be less block in the recovery room when they give you narcotic for pain. If you are on a lower daily dose– like 4-8 mg– stop the day before the surgery. In both cases you will still be partially blocked, but if they give enough narcotic you will be fine.

Don’t take Suboxone the morning of surgery. There is no need for it– the withdrawal takes 2-3 days to come on, and you are better off without the extra blockade. If you are having trouble with pain after the surgery, they should put you in the ICU, and prescribe however much narcotic it takes. The reason for the ICU is because many nurses just won’t be comfortable giving large doses of narcotic on the regular unit.

Again, Suboxone will NOT cause a person to ‘wake up’ during anesthesia– if that happens it is not from the Suboxone, it is from something else entirely. If it happens call me so I can help you get a big malpractice judgment! And afterward, tell the nurses to call your Suboxone prescriber if necessary to make sure they give you enough pain medication– I often have to get involved to comfort everyone and hold their hands so they feel safe giving the large doses that are sometimes required.

You’ll be OK.

SD

Suboxone and Epidural Anesthesia; pregnancy, delivery, and C-sections on Suboxone

I just saw a keyword from Albany NY: suboxone and epidural.  I presume this is a pregnant woman anticipating labor who is taking Suboxone.  I have had several patients deliver babies while on Suboxone;  two by C-section and one by vaginal delivery.  I also was an anesthesiologist for ten years before my opiate addiction took that away.  I miss it from time to time– it was a fun job.  The pace was perfect for my personality;  relax, relax, relax, TERROR, TERROR, relax, relax…  OK maybe it wasn’t good for me… but it was fun.  And I loved doing labor epidurals, as everyone loved me when I showed up– the women in labor, the OB nurses, the obstetrician (who could go back to bed)… even the husband, who could get some sleep as well (but only after the wife dozes off first).
As far as Suboxone, first understand that it is possible to do an epidural without using any opiate at all, and being on Suboxone doesn’t have to be a problem.  During labor for a vaginal delivery or during a C-section, either by general or by epidural (or spinal for that matter) the Suboxone is not a problem.  Yes, usually a very small amount of fentanyl is added to the infusion of and epidural and is given IV after the baby is born in a C-section.  But those steps are not critical.  In fact, my own wife hated epidural narcotics, as they always made her itch terribly, so she asked to keep them out for her last delivery.
I’ll talk about the things that are not a problem first.  It is not a problem to take Suboxone while breast feeding.  The only potential problem is that you will run into a militant breast feeding advocate who makes you feel guilty about the whole thing.  I did a literature search on the topic and found several papers for it, and one against it.  To summarize, a very small fraction of buprenorphine is excreted in breast milk;  the baby drinks the milk, and the suboxone quickly passes the mouth (skipping absorption there) and going to the stomach, duodenum, and liver.  The liver destroys almost all of the buprenorphine, as it does in adults.  For the sake of purity I do suggest using subutex at this point so that the baby is only exposed to one mosty harmless drug, instead of to two mostly harmless drugs.  In the papers I dug up there were no reports of babies becoming sedated or drugged after breast feeding from moms on Suboxone.
Now, the problems…  it can be difficult to get good pain control in a person who dosed Suboxone on the morning of surgery.  One of my patients had it all set, to stop three days in advance… but then she had an immediate section a couple hours after dosing with 8 mg (I DO tend to reduce the maintenance dose from 16 to 8 mg in people close to surgery for this very reason;  it is half as hard to get pain relief after one pill than after two.  I was called after the surgery was over and she was in the recovery room.  They had done a spinal… my first comment was that ‘an epidural would have been nice, as we could have run dilute local anesthetic through it post-op with dilute bupivicaine to treat her pain, and it would have worked well. Since they didn’t do an epidural we ended up transfering her to the ICU, where they could keep her on oxygen monitorin and dose her with huge doses of morphine– 20-30 mg at a time.  The better way would be to stop the buprenorphine three days in advance, or at LEAST cut down to a very low dose, say 2 mg per day, and nothing on the day of surgery.  Remember, agonists will ‘out-compete Suboxone at the receptor if you have enough  of it there.
Talk to your anesthesiologist before hand.  They can be hard to find, and they don’t take ownership of cases until the last minute, but try to find on and ask him or her to do your case.  Pick the one that talks opently to you, as some anesthesiologists can be odd ducks.  Don’t let the Suboxone thing get you all worked up, and keep your focus on the wonderful new member of the family.  And it really is wonderful.
This final part is the worst part.  You might be judged, and that would be a shame, but some nurse might peg you as the ‘addict mom whose baby is withdrawing’.  First, remember that ALL babies cry.  Second, remember that YOUR experience with withdrawal is nothing like the baby’s experience.  Withdrawal is not all that painful– it is suffereing that we don’t like, not pain per se.  Think about it– we feel guilty, sad, low, we feel jealous of people who are still using;  we feel mad at ourselves for not arranging things better.  The baby feels NONE OF THIS.  Not only that, your baby just squeezed through a tunnel so tight that they had to pull on his head to get him out of there.  He was gasping like mad, using fluid-filled lungs, trying to catch his breath.  So if he is crying too much, or not crying enough, or too hungry, or not hungry enough (you get the idea) give yourself a break and just ignore what people say.  Your baby is fine;  don’t treatment him like a medical specimen.  All of the data we have shows no problems with babies born to mothers on Suboxone.

Suboxone and Anesthesia; Suboxone vs. 'Recovery'

Yes, I have changed blog platforms again… hopefully for the last time! I spent the past few days learning to use the self-hosted WordPress platform. After reading the instructions about uploading the program using FTP (no small task for non-techies like me) I went to my GoDaddy hosting account and found that by clicking a couple buttons it automatically installed for me. Since then I have discovered the different WordPress templates available, the widgets, the plug-ins… cool stuff!

But back to Suboxone. One of the questions on today’s keywords was ‘Suboxone vs. Recovery’– I won’t go into that at length now but will direct interested readers to my article at Subox.info, where I give some thought to the different things that happen to personality when an addict takes Suboxone vs when an addict goes through traditional step-based treatment. The article is on one of the last pages of that web site.
Another keyword question was ‘Suboxone and Anesthesia’.
As you may know I worked as an anesthesiologist for about ten years before my career was skewered by my opiate addiction.  I still miss the job, but it probably wasn’t good for me… I joke that my arms were getting sore from pushing around that wheelbarrow full of money!  It certainly paid very well, but more than that I loved the feeling of power and control that comes with supporting a patient during surgery, or from totally relieving the pain of a woman in labor.  Anesthesiologists are always heroes in the hospital.  Some patients don’t know just how important the anesthesiologist is, but the nurses and surgeons certainly do.  I felt like a cowboy, as I raced in from home to secure the airway of a 13-y-o boy who had hung himself and whose neck anatomy was swollen and distorted… or as I ran down the hall to the operating room just ahead of the stretcher carrying a woman whose uterus had ruptured as she labored with her tenth kid.  I still vividly remember standing in the middle of the road at about two AM, after we saved the mom and baveby in that case.  It was snowing, and the city was asleep and very quiet, and as I looked at the dark windows of the house down the street I thought that I was the luckiest man in the world to have such a job.  A few years later the job was gone, and my feelings of power were challenged every day as I came to terms with all of the changes in my life– I was doing physical exams for a fraction of my old salary, the weekly dinner parties came to a halt (in seven years I haven’t been invited to a single one of the houses that I used to go to on a monthly basis), two close friends were dead (one a surgeon who committed suicide and the other Commander Shanower killed at the Pentagon on 9/11), our vacation cottage that the family loved was sold to pay the bills…
I didn’t intend to go down this path.  These thoughts used to be very painful for me, but now I can reflect and almost smile.  I see people in my practice who are facing changes in their lives, and it is nice to know what the situation feels like so that I can understand them.  I can also say with complete certainty that one cannot predict what the future holds, particularly when one’s view is colored by depression or other psychiatric symptoms.  I can also say that if an addict stays clean and works a recovery program, good things will ALWAYS happen.
Anyone interested in my personal story by the way can watch for a book that I am writing called ‘Terminal Uniqueness’.  I am trying to decide if I should post it on Twitter as I go or just wait until I am done.
Suboxone does not interfere with MOST anesthetics.  An anesthesiologist has a number of choices of general anesthetics (regional anesthetics using local anesthetics injected into areas to make things numb are not affected by Suboxone either).  A couple examples– one can do a ‘gas-based’ anesthetic where inhaled agents cause amnesia and anesthesia, or one can do a ‘balanced anesthetic’ using combinations of opiates and other IV medications, perhaps with smaller amounts of a gaseous agent as well.  Suboxone WILL block the opiate portion of this anesthetic, but there are plenty of other agents to use to replace the opiates.
The main problem comes after the surgery in the recovery room, when Suboxone prevents morphine, demerol, and other medication from controlling the surgical pain.  One of my patients had an emergency C-Section shortly after dosing with Suboxone and it was difficult to get her pain under control.  Eventually she was transferred to the ICU for close monitoring as they gave her huge doses of morphine– which eventually controlled her pain.  Some surgeries will be of a nature where injections of local anesthetic can provide considerable pain relief for up to twelve hours.  This is a particularly good option for procedures on the extremities.  Sometimes an epidural can help a great deal with pain control after abdominal procedures, or even chest procedures.  In cases where opiates need to be used, the dose will usually need to be surprisingly high, at levels where nobody will be comfortable unless the patient is continually monitored for respiratory function in a step-up unit like the ICU.

I have helped six or seven Suboxone patients through the surgical process and for the most part they have done well.  Stopping Suboxone for three days prior to surgery will make pain control much easier after the surgery.  Even if sufficient time has elapsed to get rid of the Subxone, though, the person will still have a much higher tolerance than patients not on Suboxone, so I strongly recommend discussion the fact that you are on Suboxone with your surgeon and your anesthesiologist.  If you don’t, they won’t know what is going on, and won’t be able to take the proper steps to help you.
SD
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