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.
Acute Pain
VA Gets it Right and Wrong on Buprenorphine
The Veterans Administration recently released guidelines for chronic pain that recommend using buprenorphine if opioids are indicated. That idea has some validity, but the VA, and commenters, get much of the issue wrong. Buprenorphine is Read more…
15 Comments
moman · March 24, 2011 at 7:20 am
My experience with surgery while on suboxone was not good. I though it did everything right….took my , meds to the hospital (I had hip surgery, no warning), told all the docs, etc. They put me on a PCA, under-dosed me, and kept giving me suboxone. It took two days before my sub doc intervened and told them to stop the sub. By then, I was two days out from the OR.
Nothing seemed to work, and being an addict who tried to be honest, I always got less instead of more. The dressing changes were awful, even though they added 80mg oxycontin BID to the MS. When they discharged me, they unplugged the PCA, scripted me 10mg OC BID, plus Norco. It never controlled the pain and I slowly went into withdrawals, until I gave up and restarted my subs on my own.
My opiate addiction began after an accident left me with 2nd and 3rd degree burns to 15% of my body. I was honest then, and never will forget the first debriding session….with nothing given for pain. I fought em off, and got ONE Darvocet. The next day, they started me on Demerol IM PRN. After a month of that misery, a pain doc finally was called and told me all this stuff was exactly the wrong thing for me. He put me on Brompton’s, and slowly weaned me off. I would never wish this on anyone!
Martie777 · January 24, 2012 at 10:02 am
This information is greatly appreciated and vital, but how do we, as patients explain this to our doctors? In my opinion, a Dr. Should not be allowed to prescribe Suboxone unless he/she is on board with a universal protocol to deal with acute or post operative pain.
SuboxDoc · January 27, 2012 at 11:41 am
Agreed. There will always be bad doctors, but they become even more of a problem in the absence of good doctors…. so I think we need more doctors willing to do the ‘dirty work’ of treating opioid dependence. If patients had more choices, the bad doctor practices would wither away.
Karisa · April 7, 2017 at 12:08 am
I know I’m 5 years late but this is the most helpful info I’ve found. I’m in the hospital Right Now. Gallbladder removal 18 hours ago. I’ve been on Suboxone 6 years for heroin recovery & chronic pain. (No relapses in that time)
The pain here is SO bad. I’m getting 4mg of morphine every 6 hours. Think they plan to send me home with Norco. I’ll deal with what I have to for now. The thing I’m TERRIFIED able is getting back on my suboxone routine.
I got Hydrocodone for a pulled tooth 4 years ago. Waited 12 hours from last Hydro. dose & took a suboxone film & was sent into agonizing precipitated withdrawals.
Many forums say one must wait 24 hours.
I’m so scared of detox. I felt I had no choice but to take there opioids (which are only barely taking the edge off – I’m trembling & hurting & can’t sleep after being awake almost 24 hours)
What do I do? What do I do?
Please oh please someone out there see this & help me.
P.S. My sub prescribing doc is gonna be so pissed at me for accepting morphine. I don’t know if she’ll be any help.
Jeffrey Junig MD PhD · April 7, 2017 at 1:37 pm
I sent you an email; not sure if you received it, but I’ll copy it here for other readers:
Read this: http://suboxonetalkzone.com/post-operative-pain-in-suboxone-patients/
I just got off the phone with a surgeon, planning pain control for upcoming surgery in one of my patients. That’s what happens in ideal situations. There are two approaches—both described in an NIH consensus paper about the issue. One approach is to stop buprenorphine; the other to keep it going. I do NOT like stopping buprenorphine before surgery for several reasons. First, it takes weeks to leave the system, and even if it does leave the system, you are left going into surgery depressed, dehydrated, and malnourished because of withdrawal. Even if you stop buprenorphine, tolerance remains elevated– so high doses of opioids are needed to provide post-op pain relief.
So instead, I tell patients to reduce their buprenorphine dose by half, but stay on it EVERY SINGLE DAY. Then I treat post-op pain with a higher dose of agonist than usual. Note that morphine is a WEAK agonist; it does not effectively compete with buprenorphine, even the residual buprenorphine left after stopping the drug for a week. You need a potent agonist like Opana, or oxycodone, or Dilaudid.
I typically use oxycodone, 15-20 mg every 4 hours. The patient stays on buprenorphine or Suboxone every day. The result is that the person gets pain relief, but does not ‘feel’ the opioid. There is no euphoria, and usually no sedation—but it does relieve pain if the dose is high enough.
Patients can often control the agonist, as long as they stay on buprenorphine. But to be safe I usually give scripts to cover 2 days, each with a ‘fill after’ date, so that the person never has a large number of pills at home.
The nice thing about this approach—continuing the buprenorphine or Suboxone every day—is that when you stop the opioid agonist, you can simply go back to your full dose of buprenorphine, with no risk of precipitated withdrawal.
Feel free to share my email with your doc; understand that no doctor appreciates advice from other doctors though. Good luck!
Summer G · January 4, 2018 at 11:44 pm
I am having a serious knee surgery this Monday 1/8/18 after 6 surgeries back to back around 10 years actually 14 total I was on Norco 10 325 at a rate of 20 plus per day. I wasn’t trying to get high yadyada. I found an outpatient suboxone doctor and it’s saved my life. I am clean for well over 7 years. I take a level dose of subutex daily to help with pain management. I’m at 8 mgs daily but have been tapering on my own to 2 mgs 4 days to surgery. I’ve kept my surgeon and doctor informed. I’m terrified of withdrawals I already feel poorly and I know I’ll never go back to opioid pills but I know I’m gonna need relief of pain. My surgeon knew nothing about bikes. I had to explain. Help folks. Some actually info to give him and my anesthesia doc. The surgeon has no idea giving me pain pills. I want to minimized those and stay on my subutex.
Jeffrey Junig MD PhD · February 1, 2018 at 7:48 pm
I’m sorry– it may be too late for this. But I have tons of info on my blog, including info that can be given to surgeons (who are welcome to contact me if necessary). You will find them by using this blog’s search function for terms like ‘acute pain’ or ‘post-op pain’ or ‘surgery on suboxone’. Another option is SuboxSearch, where you can search either this blog or my forum for those terms. Check it out– it is very useful!
It is completely, 100% possible to provide adequate pain control after surgery. Doing so requires ordering doses of medications that uneducated nurses or doctors will resist. Doctors and nurses who are smart-enough to understand buprenorphine (and they all are smart enough) and who have gained a little experience with such care, will have no problem with the pain control. DON’T LET YOUR OWN SURGEON CHICKEN-OUT. If your surgeon says ‘I can’t treat your pain on Suboxone’, tell that person to FIND SOMEONE WHO CAN.
I am getting tired of the ignorance out there, and how after 14 years, most surgeons STILL have no idea how to manage a patient on buprenorphine.
coryguy52 · May 10, 2017 at 6:58 pm
Hey Dr. Junig, I’ve been an avid reader of this site and even sent you a text about “The Look.” You know, the look we get when we tell an ER doc or nurse that we are on Subs. Well sir, I’ve been giving this a lot of thought and I think I’m going to try to start weaning off of the Subutex through my Sub Dr. There are a lot of reasons for this move. After the horrifying experience I had last Summer with the terrible pain I was in and all the medical “Professionals” would address was the fact that I was on Subutex!! Yeah, no kidding, I tried to be above board and honest, so I told them the truth. Anyway, I’m 58 years old and a raging diabetic along with Arthritis and a few other maladies. OK, now I’m going to be as truthful to you.. These problems I’m having are leading to some pretty painful nights where I’m getting little to no sleep. These Drs. are telling me that the Subutex is as strong as a Percocet 30Mg. OK I’m no Dr. or have any pharmacological schooling, but, if Subutex is only a partial agonist, how can it be as strong as a Perc 30? Anyways back to the honesty part, I hope that once I’m off of the Bupe all together then maybe I can start taking some pain meds at night so I can at least get some sleep. I’ve NEVER had a dirty urine in over 5 years while on Bupe. Went to all of my counselling sessions, always paid in full every month. I was the perfect Bupe patient. (Not Bragging) I did get into heated arguments when they told me I had to use the strips instead of the generic Subutex. And that argument still arises every so often. I just don’t get it, if I had any other disease there would be no problem getting a generic medicine for it. But for this, it’s a HUGE problem. And when I ask why I get double talk. So, with everything I’ve listed here and a few things I didn’t, I think it’s time to start the process of weaning down to eventually be completely off of bupe all together. Please tell me what you think, I really wish I lived near your practice, I would definitely be one of your patients. It just seems like you “Get It” Dr. J. A lot of these other Doc’s don’t. Your patients are very lucky to have you. Please let me know what you think, looking forward to hearing from you.
Jeffrey Junig MD PhD · May 10, 2017 at 8:21 pm
Thanks for the nice comments. Yes, I remember our earlier communication, and I understand the look and attitudes that you describe. Buprenorphine does have potent opioid effects comparable to 30 mg of oxycodone, but your doc is missing the tolerance issue, which removes almost all of the opioid effect of buprenorphine after a few weeks on the medication. Tolerance takes longer to develop, and develops less completely, when people take a drug like oxycodone that leaves the body within a few hours. In contrast, buprenorphine’s ceiling effect allows for constant opioid activation across the entire dosing period.
I’ve written posts over the years about the unfortunate status of people with chronic pain. There are a couple aspects to the chronic pain debate where the figureheads from the medical side– the medical societies and organizations that often provide soundbites about medical politics, or groups like “Physicians for ‘Responsible’ Opioid Prescribing” that encourage politicians to remove doctor autonomy- are either not being honest, or are not putting on their ‘thinking caps’ before speaking about the issue. For example…
Doctors often distinguish between acute pain and chronic pain. If a doctor says that acute pain, such as major surgery or a broken femur, doesn’t need treatment with opioids, anyone listening will consider that doctor to be an insensitive fool. We know from mountains of studies that untreated postop pain leads to increased stress responses and increased morbidity and mortality. The need for opioids in such situations is obvious, and withholding them would not be humane. At the same time, doctors often say that opioids are NEVER indicated for chronic pain– as if there is a qualitative difference between the experience of pain in one case vs. the other. But what if the pain experienced by some people with chronic pain is WORSE than the pain experienced by patients after surgery? There is no evidence at all that chronic pain is less severe. Maybe, since it goes on so long (and patients with chronic pain are treated in the way that you described, made to feel like criminals for seeking pain relief), the suffering is greater! The dichotomy between acute and chronic pain is artificial, and created ONLY so that doctors can feel better about denying pain medication to chronic pain patients.
Also, the same experts would say that opioids don’t help, and possibly make chronic pain worse. But there are ways to treat chronic pain with opioids that DO work. I’ve tried to raise awareness of those approaches over the years, presenting one approach at ASAM, but there is little hope for the methods to go mainstream given the current atmosphere. I even shared one of them with one of the founders of PROP a few years ago, and he dismissed it without trying to understand the neurochemistry behind the approach. The approaches rely on combinations of agonists and partial agonists, such as buprenorphine and oxycodone, where buprenorphine prevents the maximal stimulation of the mu receptor by agonists, but allows enough stimulation to provide analgesia… without tolerance formation, euphoria, or addictive ‘pull’.
I thought I discovered that approach, but found while researching the combination that others have described the phenomenon for many years. The approach involves combinations of generic medications, so I don’t see much motivation for pharmaceutical companies to get involved- but one would think that more doctors out there would have empathy for the millions of people struggling with chronic pain.
I’ll get off the soapbox for the night. But I understand your frustration. I hope you’ll use SuboxForum during your taper, as there are always people there working toward that same goal- and the support is helpful during those sleepless nights. I’ll likely see you there!
coryguy52 · July 2, 2018 at 4:39 am
Hi Dr. Junig, Well, it’s been a little over a year since I started my taper and I’ve gone from 24mgs. to 8. I know I still have a ways to go but the SuboxForum helps me so much!! No matter what questions I have all I have to do is go to the forum and sure enough someone has already asked and you have answered it. You should consider opening a satellite office here in Pittsburgh. I’d be your first patient!! Thanks again for all of your hard work!!
Jeffrey Junig MD PhD · July 26, 2018 at 5:25 pm
Hey, I appreciate your comments! Just an FYI- I put up a site called SuboxSearch where you can search either this blog or that forum. It will pull out every post or comment about any topic. Good luck with your taper!!
Corey D · January 29, 2018 at 10:42 am
Hi there, I have been doing so much research today since I’m having an oral procedure in 2 days. I’m on 4 mg of Subutex, although I’ve been taking 8 mg the past 3 days hoping it’d cut the acute pain I’ve been having the entire weekend. I went to my dentist this morning, and they have to extract 2 teeth. They’re going to sedate me, although not with an IV. They said they will give me Xanax & Halcion to put me under, then remove the teeth. I’m worried that those 2 medications might be dangerous having been on Subutex for 2 years.
The only other medication I’m on is 20mg of Vyvanse for ADHD, but I don’t forsee that being problematic. I’m desperately hoping that although this is an older post, someone out there can respond within the next 48 hours. If not, I’m thinking about calling and cancelling my sedation and just baring with the fear, anxiety & pain being awake while the cut open my gums to take the teeth out (one is broken with almost nothing above the gum line). The dentist knows I’m on Subutex, but I get the feeling he doesn’t really even know much about it at all. I called my Sub doctor, and they just said “if your dentist thinks it’s fine, it’s fine.” But I don’t really feel good about that answer either. Do you have any experience with these medications being used to sedate someone while on Subutex/Suboxone? Thank you sooooo sooo so much in advance!
Jeffrey Junig MD PhD · February 1, 2018 at 8:58 am
Hopefully you saw my answer at http://www.suboxforum.com — those medications are ‘benzodiazepines’ that can worsen respiratory depression caused by opioids. But you are tolerant to those effects from buprenorphine, so the risk in your case is very low, assuming they don’t give huge doses of those two drugs. I’m not sure why they would use both Halcion (triazolam) and alprazolam; they have identical actions, but different half-lives.
ChestNUT · February 27, 2018 at 5:02 am
Thank you for your article! I am a 59 year old woman with chronic pain. I recently began a suboxene program for my pain. I was on rather high doses of oxycodone for years. The suboxene has relieved my pain almost entirely! I need back surgery, but am putting it off for now . I do have side affects however. I cannot taste food, feel eye drops rolling down my face or even feel my bowels move. It is wonderful to not be in pain though! I’ve had great concern about being put under for some reason. Your article has validated my fears! I’m hoping to resume life with no medication after surgical pain. Suboxene really does work for pain in some people , I’m living proof! I only took the oxycodone that I was prescribed by my physician by the way .. he did me no favors. Thanks again. ..♥
Lana-jo · October 22, 2018 at 12:46 pm
Hi in desperate need of advice I’m on buprenorphine 1.4 ml I booked and paid for a breast augmentation to the cost of £6,350 I disclosed my medical records as requested today Monday 22nd Oct I had a phone call at 3.45 to tell me my surgery scheduled for tomorrow the 23rd was cancelled also there saying the small print states I may not get my money back please help