I don’t have pull with the addiction-related organizations out there. I’m never been a joiner, and I tend to notice the problems caused by medical societies over the good things that they supposedly accomplish. For example PROP, or ‘Physicians for Responsible Opioid Prescribing’, have a specific mission. Once a group has a mission, any considerations about individual patients go out the window. PROP has propagated the message that opioids are NEVER beneficial for patients with chronic pain. But can we have opioid analgesia without addiction?
Legislators with no knowledge of clinical medicine hear that message, and respond by passing draconian laws that interfere with any considerations of individual patients. I would guess that the people of PROP pat themselves on the back for encouraging laws that remove physician autonomy. I’m sure they figure that they are smarter than all the family practice docs out there. But in reality, they are only destroying the control of doctors over patient care, and handing that care over to politicians. Way to go, PROP.
In the same way, the societies that hold meetings about meetings, that elect Secretaries who become Vice Presidents who become Presidents, get to publish the articles that describe clinical protocols. The doc who spends every day talking with patients has no access to these sources, and little ability to influence those protocols. Sometimes the societies and organizations get things right… and sometimes they get things wrong. The latter is the case with post-op pain control in patients on buprenorphine products.
I’ve written about this before, as regular readers know. Over the past 8 years I’ve had dozens, if not hundreds, of patients on buprenorphine undergo surgery. The surgeries include coronary bypass, thoracotomy, rotator cuff repair, C-section, nephrectomy, total knee or hip replacement… and a host of minor surgeries with scopes and lasers. I’ve treated these patients in a number of ways, in part because hospitals that provide emergency care have different ways of dealing with post-op analgesia. I rarely have control over what they do acutely– but I almost-always take over pain control when patients are discharged.
In the past few months there have been several ‘articles’ stating that the best way to handle surgery, in people on buprenorphine products, is to stop the buprenorphine before surgery, and treat pain using opioid agonists. This opinion is not supported by any data. It is someone’s opinion– usually someone who has a title, i.e. someone who spends at least some of his/her time in society meetings. That time is removed from the amount of time that could be spent treating and speaking with patients. Frankly, the ‘higher’ a doctor is in society circles, the less time they spend in patient care. That comment will anger the docs who it applies to. I can hear them now– saying I’m only full of ‘sour grapes’. But maybe those same docs should look in the mirror, and wonder how they ended up as ‘President’ of a society.
I’ve used the approach claimed as best practice in the society journals– i.e stopping buprenorphine before surgery– and the same thing always happens. Tolerance to opioid agonists rises very rapidly in the post-op period. Patients are discharged on huge doses of opioid agonists. And at some point, agonists must be discontinued for 24 hours to allow for re-induction with buprenorphine agents. I’ve had several recent patients go through this exact process– and my frustration motivates this post. One guy shot himself in the femur, and the bullet also passed through his lower leg. He needed fasciotomy to avoid losing the leg. His Suboxone was discontinued at admission, and ten days later he was discharged on 30 mg of oxycodone every 2-3 hours– i.e. over 200 mg per day. The other person was in a serious car accident, and had multiple fractures— femur, pelvis, ribs, wrist– as well as internal injuries. After 3 weeks he was released on over 300 mg of oxycodone per day!
On the other hand, I’ve had many patients go through the surgeries listed earlier while maintained on buprenorphine, 4-8 mg per day. In ALL cases, they had excellent analgesia with lower doses of oxycodone than in the people who stopped buprenorphine. Most patients did well on 15 mg of oxycodone every 3-4 hours– a max of 120 mg of oxycodone per day. In a few cases– i.e. in the most painful operations, in the most sensitive patients– I had to use 30 mg of oxycodone every 4 hours.
The most amazing thing about the combination of buprenorphine and opioid agonists is the absence of tolerance to agonists, when buprenorphine is present. I’ve had patients with recurrent injuries that required repeated surgeries, including a woman who tore her rotator cuff and the surgical repair THREE times over three months. She took the same amount of opioid agonist for three months, with no noticeable decrease in efficacy. After the final operation, after three months on significant amounts of opioid agonist, she simply stopped the agonist and resumed her full dose (16 mg) of buprenorphine. She had no withdrawal, and not other complications. She simply stopped the agonist and resumed buprenorphine treatment.
I’ve come to realize that buprenorphine effectively ‘anchors’ tolerance when patients take opioid agonists, as long as the buprenorphine is continued. Patients always say the same thing: that the pain was reduced by the agonist, but that it didn’t ‘feel’ like the agonist they used to take. In fact, patients who could never control pain pills found that they COULD control agonists if they stayed on buprenorphine.
A couple years ago I presented these findings at an annual meeting of ASAM. The slides can be found here. I believe that some day, combinations of buprenorphine and opioid agonists will be the standard approach to pain treatment. The combination allows for opioid analgesia without tolerance, without euphoria, and with little or no risk of addiction. If THAT doesn’t piqué your interest, you have no business reading about opioid dependence!
I picture combinations of buprenorphine and fentanyl… especially since both are now FDA-approved as transdermal patches. Or perhaps a combination of fentanyl lozenges and sublingual buprenorphine. The possibilities are endless. Throughout history, the miracle of opioid analgesia has been cursed by the attachment to tolerance, dependence, and addiction.
Imagine if that curse was lifted from opioid analgesia. Can you even dare to imagine that world? I’m telling you… it is closer than you think—- and there for the taking.
Jhuey · June 1, 2017 at 1:27 am
Dr.Junig I need your help with my doctor I’ve been on bupe for 5 years now for chronic pain it isn’t helping me at all my quality of life is going down the drain due to my pain it’s all I can do to get through the work week I hurt so bad my Pcp mentioned switching me to morphine or oc my last appt he said he would have to do some research on what to do and he would get back with me and he did and he told me he spoke to his colleagues and switching me would be a tough transition and using high amount of opiods he said he didn’t want to do that and they said to up my dosage to 20mg first and then to 24mg I’ve already been down this road before I was taking 32mg a day for a year with no relief in pain I’ve even cut myself down to 4mg and still no releif so what im asking you what would you recomend him do if he switches me you are loaded in knowledge on this matter and I could use your input and maybe he would help me after he told me this I was blew away, so because I’m on subutex I have to suffer in pain the rest of my life???? Please help
Jeffrey Junig MD PhD · June 6, 2017 at 9:51 am
I understand your problem, but don’t know if a great solution. As you know, there are many forces pushing doctors from prescribing opioid agonists these days. I fear that things will probably swing too far, as that’s how things usually work out with clinical trends. I try to point out to other physicians that we have an artificial divide in our minds between acute and chronic pain, where doctors assume that acute pain warrants narcotics, but chronic pain doesn’t. My point is, what if a person has chronic pain that is actually more severe than acute pain? For all we know, the pain of a patient with ‘failed back syndrome’ may be worse than the pain after gallbladder surgery! No doctor would ever argue that people should go through gallbladder surgery without narcotic— so avoiding narcotics in the failed back patient might be inhumane treatment.
That is my soapbox, but it doesn’t help much in a practical situation like yours. I would just say that your experience is not unusual. Buprenorphine sometimes provides surprising pain relief… but it usually does not help with severe pain, because of tolerance. And you are correct– that you are unlikely to get much more pain relief once you raise the dose above 8 mg, no matter how high it goes. There are some suggestions from studies that non-mu receptors mediate some of the analgesia with buprenorphine, and that’s why higher doses are tried…. but the analgesia from kappa and delta receptors is minor, and not helpful in people with severe pain.
You could change back to agonists, but understand if you do, tolerance will drive your dose higher and higher.
So… as I wrote in this blog post, the only option for someone with severe chronic pain is to stay on a low dose of buprenorphine– about 4 mg per day– and add about 10-15 mg of oxycodone every 4 hours. When I’ve used that combination, I’ve seen patients get good pain relief for an indefinite time, without signs of tolerance. The combination attracts a lot of attention, of course, because insurers and regulators are confused by a person taking both medications… but from a scientific standpoint the combination makes sense. The person MUST start the buprenorphine first, though– and if the buprenorphine is ever discontinued, the person must stop the oxycodone for at least 24 hours and ‘re-induce’ with buprenorphine before taking oxycodone again.
This combination appears to have few risks, but I do not know of any studies of the combination– so there could be unknown risks. I would use the combination only in the worst cases– people who clearly have a very poor quality of life in the absence of opioids.
Finally, if your doc decides to switch you to an agonist alone– say to just methadone or oxycodone, without buprenorphine– he would want to use an amount of opioid with a potency similar to 40 mg of methadone. That value is well-known to buprenorphine prescribers– that the ceiling effect of buprenorphine is about equal to 40 mg methadone. There is no need to wait for the buprenorphine to disappear; the agonist can be started, and it will slowly take effect as the buprenorphine level drops.
Jhuey · June 6, 2017 at 6:39 pm
Thank you very much doc I will show this to my Pcp and I really enjoy your blog and forum very helpful god bless