Broken Bones on Suboxone; Need Pain Relief

Originally Posted 1/11/2014
I received the following email from a Suboxone patient (from another practice) after he experienced a painful injury.  He shared what happened at the hospital when he was trying to get relief from pain, while taking Suboxone (the active component is buprenorphine).
Hey there.  Just to let you know, i was on 24 mg of Suboxone when I jumped off a fence and crushed bones in both feet.  The injury was among the most painful things I have gone through in my life.  At the hospital they did not understand Suboxone even though I tried to explain to them how it worked.  They couldn’t get a painkiller to break through and I was nearly passing out from the pain.  They finally used Ketamine and it worked immediately.  However, they only used it 3 times and its effect don’t last more than about 20 minutes in my case.  Then they switched to IV Fentanyl….I’m not sure of the dose but I know it was high and after a few injections they hooked me up to a drip bag.  Just wanted to share this info in case anyone finds themselves in a situation like mine where I was ready to strangle a doctor because they tried all of the regular oxycodone, hydromorphone, morphine, etc. all the while I was almost (or maybe even) in a state of shock from the pain.
Hope this can help someone out in the future.
I wrote back the following message, with a few minor changes:
Thank you for sharing your story.  As you may know, I was an anesthesiologist for ten years before developing my own addiction to pain medications.  I have been in the position, many times, of treating pain in patients after surgeries or accidental injuries.  Pain relief is possible in every case, if a competent doctor takes the time and effort to control the pain.  There are arguments within the field of medicine over the use of narcotics for chronic pain, but those arguments do not extend to acute pain.  There are no reasons a person should be allowed to suffer from pain in a US hospital—beyond incompetence or failure of the system.
Buprenorphine complicates pain treatment in two ways; by blocking mu receptors and by contributing to a higher opioid tolerance. Opioid agonists (pain medications) compete with buprenorphine for binding at mu opioid receptors.  Larger doses of buprenorphine cause greater blockade of mu receptors, requiring larger amounts of agonist to treat pain.  When I read your description of the different things tried, my impression was that your pain control was delayed by your doctors trying too many things, instead of sticking with one thing until it worked.
Some opioids (notably morphine) trigger histamine release, which causes hives, lowers blood pressure, and limits the dose that can be given in a short amount of time.  Large doses of high-potency opioids like fentanyl or sufentanil cause muscles to tighten, and in rare cases cause rigidity of the chest that interferes with breathing.  But that side effect is rare, and not a major concern in modern acute care facilities.
For the most part, oxycodone (oral) or hydromorphone or fentanyl (IV) could be given in almost infinite amounts, and at some dose either medication will provide pain relief.  Doctors should remember their training from medical school, when they learned to focus on the patient rather than the numbers.  In your case, nasal oxygen and pulse oximetry should have been applied, and attention directed to your respiratory rate. Oxycodone (oral) or hydromorphone (IV) should have been titrated upward until your respiratory rate was 12-14 breaths per minute.  At that point you would have been relatively comfortable.
Anesthesiologists regularly use respiratory rate to determine whether additional narcotics are indicated in patients near the end of surgery.  The dose of hydromorphone (Dilaudid) necessary in your case may have been high, but respiratory rate decreases gradually as opioid effect increases and pain is relieved, allowing for safe use of virtually any amount of narcotic. The term for this type of care is ‘titrating to effect.’ With appropriate monitoring (present in every ER, OR, recovery room, or ICU), titrating in this way is very effective.  Some hospitals place limits on intravenous opioid doses on general med/surg units, but there are no such limits in units with 1:1 nursing, oxygen, and pulse-oximetry.
There were other ways to provide pain relief, depending on whether you were the hospital CEO, a major donor, or a guy labelled a ‘drug addict.’  They could have placed an epidural and run local anesthetic at a dose low-enough to allow you to walk with assistance while greatly reducing your pain.  Or they could have used a higher dose of anesthetic that provided complete pain relief.  Higher doses of anesthetic cause temporary muscle weakness that may have kept you from walking, but you probably weren’t walking anyway, given the injuries you described.
Readers are invited to use the ‘share’ button to create a print-friendly version, and to place a copy in your wallet—in case you ever find yourself in a buprenorphine knowledge-free zone!

11 thoughts on “Broken Bones on Suboxone; Need Pain Relief”

  1. I broke my foot yesterday in two spots on the top under my toes, I cannot walk on it the pain is out of this word my toes are numb and burning and I am a suboxone patient. The DR in the ER showed me the x-ray and said “yup you broke it alright two spots” showed her medical student examined my foot and asked me if I was using IV drugs I told her I was 4 years clean and she laughed EVERYTHING OFF and said well go home put ice on it take A LOT of motrin or Tylenol and watch some tv. I asked her for anything that could work against the subs and she ignored me she said wrote a script for over the counter valtrex topical pain relief and walked away. I am a grown man 46 years old farmer and father and I cannot seep the pain is so terrible. What should I do.

    1. I am sorry about your situation. There is an easy solution, but I don’t know if you will be able to find it. What SHOULD be done, when opioids are warranted, is to treat the pain with a higher dose of oxycodone (i.e. the drug in percocet). When my own patients are in your position, I talk with the doctor who saw the patient and ask one question: ‘if this person was not on buprenorphine (Suboxone), how would you treat the pain?’ If the answer is ‘with vicodin, for 3 days’, then I provide oxycodone for 3 days, and have the patient continue buprenorphine each day but reduce their dose by half. That is my approach with surgical pain as well– I reduce their dose of buprenorphine by half starting the day before the surgery, and then I ask the surgeon how he/she would treat post-op pain if the person was NOT on buprenorphine. I treat the person for the same length of time as the ‘non-buprenorphine’ patient, but I use a higher dose of opioid. Every patient is different so I don’t want to predict the dose for people, but generally 15 mg of oxycodone every 3-4 hours provides reasonable pain relief for patients taking 8 mg of buprenorphine per day.
      No doctor likes to be told what to do, but if your buprenorphine doc is interested in my opinion, feel free to share my comments here.

      1. I’m a patient prescribed Suboxone for chronic pain issues. Because of the politics behind opiate use. And I feel your pain. There’s been many times when a pharmacist fills my prescription and has a discus look on her face. I am an alcoholic and I know what discrimination looks like. I am seven years sober. The so called care giver pledge is one I almost never see to often. I am dealing with a torn tendon in my shoulder and am looking for help. I take less pain management med than perscided and wanted too know what could help.( I have also taken 3mg of tylenol today.)
        I am always grateful for any advice.
        Thank you

      1. Thank you for your comment and yes it has seems like the first several days were the worst now its avbout 3/4 out of 10 nothing advil and my suboxone wont take care of. Blessings!

  2. I broke my foot yesterday in two spots on the top under my toes, I cannot walk on it the pain is out of this word my toes are numb and burning and I am a suboxone patient. The DR in the ER showed me the x-ray and said “yup you broke it alright two spots” showed her medical student examined my foot and asked me if I was using IV drugs I told her I was 4 years clean and she laughed EVERYTHING OFF and said well go home put ice on it take A LOT of motrin or Tylenol and watch some tv. I asked her for anything that could work against the subs and she ignored me she said wrote a script for over the counter valtrex topical pain relief I asked her for a shot of toradol or something to help the pain till I see my Addictions DR she said “Aw nope this wil help the pain and not the rest of your body” ? and walked away. I am a grown man 46 years old farmer and father and cannot seep the pain is so terrible. Clearly again even asfter nearly4 years of staying clean she used ignorance and treated me like the usual drug addict attitude you get from young doctors What should I do.

    1. my email informed me my posts were ignored because they had some other address associated with this account? a glitch of some kind. Thank you Dr Junig for the validation, sucks in a small town no matter how long you stay cean you are a drug seeker to some dr;s especially young ones and couldnt even get a shot of toradol just three tylenols extra strength lol

      1. If you tolerate ibuprofen, you can take up to 100 mg per hour– so the best treatment would be either 600 mg every 6 hours or 800 mg every 3 hours. You can take that along with the tylenol, as they work in different ways. And the foot surgeons I worked with back in my anesthesia days always stressed the importance of elevation, because the swelling really increases the pain. And yes- I know what you mean about the attitudes out there!

  3. I broke my foot yesterday in two spots on the top under my toes, I cannot walk on it the pain is out of this word my toes are numb and burning and I am a suboxone patient. The DR in the ER showed me the x-ray and said “yup you broke it alright two spots” showed her medical student examined my foot and asked me if I was using IV drugs I told her I was 4 years clean and she laughed EVERYTHING OFF and said well go home put ice on it take A LOT of Motrin or Tylenol and watch some tv. I asked her for anything that could work against the subs and she ignored me she said wrote a script for over the counter valtrex topical pain relief I asked her for a shot of toradol or something to help the pain till I see my Addictions DR she said “Aw nope this wil help the pain and not the rest of your body” ? and walked away. I am a grown man 46 years old farmer and father and cannot seep the pain is so terrible. Clearly again even after nearly 4 years of staying clean she used ignorance and treated me like the usual drug addict attitude you get from young doctors What should I do.

    1. I just answered your post yesterday:
      broke my foot yesterday in two spots on the top under my toes, I cannot walk on it the pain is out of this word my toes are numb and burning and I am a suboxone patient. The DR in the ER showed me the x-ray and said “yup you broke it alright two spots” showed her medical student examined my foot and asked me if I was using IV drugs I told her I was 4 years clean and she laughed EVERYTHING OFF and said well go home put ice on it take A LOT of motrin or Tylenol and watch some tv. I asked her for anything that could work against the subs and she ignored me she said wrote a script for over the counter valtrex topical pain relief I asked her for a shot of toradol or something to help the pain till I see my Addictions DR she said “Aw nope this wil help the pain and not the rest of your body” ? and walked away. I am a grown man 46 years old farmer and father and cannot seep the pain is so terrible. Clearly again even asfter nearly4 years of staying clean she used ignorance and treated me like the usual drug addict attitude you get from young doctors What should I do.

  4. I apologize for the glitch somehow my phone old owner stil had been signed in and inmy email it said I was denied to post when it actualy did… 3 times lol I apologize. I do take the ibuprofin )motrin) and it does reduce swelling like half buy pain is still really bad especially if I put any weight on it. I did go yesterday and see my addictions DR and I showedhim your post and the link to your clinic and he prescribed me supeudol 5mg oxycodone and told me to take my subs but 4 times a day rather than the whole lot at once. it has worked but seems to wear off fast I wonder if I took 10mg 3 times a day would work better. Also thank you Dr Junig you played a role in helping me seek treatment up here in Canada. My Doc also apologized for the ignorance of young Dr who have a prejudice attitude toward recovering addicts. Ill be clean 4 years Aug 13. Thank you once again Dr Junig

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