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?
This article is a little dated, so after reading go to this link for updated opinion.
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 of 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 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.
kara · November 29, 2008 at 8:24 pm
When you say that you augment pain medication, how do you do so? Do you write a script for something? And, if so, what? In recovery, I’m sure they will use morphine or something similar, but I am worried about what to do once I am at home. It is an outpatient surgery, so I will be leaving that same day. Based on my sub use (8mg for last 2 years), I went down to 2mg and took my last 2mg dose Wed. What do you think my tolerance is and how much pain medication will be needed to overcome that? I am going to see my sub doctor on Monday and I don’t know what/how to ask for something. I don’t want to ask for something I don’t need. I am also aware that a sub patient asking for meds is a bad situation. Any advice on how to handle this and what to ask for? I love the sub, it has changed my life for the better but what a pain (pardon the pun) all of this is!!
SuboxDoc · November 29, 2008 at 10:19 pm
You have done a great job in tapering down in preparation for surgery. It isn’t easy to do– even though there isn’t a big difference between the effects of two vs eight mg, the mind plays tricks on you– as you probably know– making you think that you are withdrawing. But by going to two mg, and now stopping for several days, your receptors should be available for pain meds to work after your surgery.
As far as your tolerance, the level of the ‘ceiling’ with buprenorphine is equal to 30 mg of methadone. That is about equal to 50 mg of oxycodone. Your tolerance may drop a bit from Wednesday to Monday… understand that all of this is guesswork and approximation… but if you were my patient I would give you tablets containing 15 mg of oxycodone, and have you take one or two every 4 hours. Yes, I prescribe pain pills for my patients under these conditions. But I am Board Certified in anesthesiology and so I am more comfortable doing that than some psychiatrists or addictionologists might be. That stinks, though– what are you supposed to do? This issue is one of the things about modern medicine that really stinks– docs are compartmentalized into all these specialties so nobody can take ‘total care’ of a patient! Too often doctors hide behind comments like ‘that isn’t my area’, or ‘I can’t do that under my malpractice insurance’. Or they just lie, like your nurse practitioner did, and pretend that there is some law against doing what they should be doing.
I would encourage you to try not to feel guilty for asking for pain medication. Yes, I know what you are saying– I have been there myself. But there is nothing about being an opiate addict that makes you less sensitive to pain! And regardless of what ‘society’ sometimes seems to think, you don’t deserve to be punished. You have already done penance 100 times over for the mistakes you made that led to addiction. So with your Suboxone doctor, just say, ‘I’m having surgery, and knowing that being on Suboxone has raised my tolerance, I’m concerned about getting sufficient medication to treat my pain’. If your doc says ‘it won’t be a problem– just take what the surgeon gives you’, then you will have to ask the surgeon and hope he/she is enlightened, and not a total jerk.
If you end up getting percocet, all is not lost– but if it were me, I would tell the surgeon about my tolerance being high because of an ‘opiate blocker’, and word the question in terms that affect the surgeon– like ‘it will be such a pain for you if I have to go in to the ER with pain, or if I have to call you in the middle of the night… please help me so I don’t have to do that’. All us docs ultimately are most concerned about ourselves! You don’t want to exceed 4 grams of tylenol in 24 hours, so check the amount of acetominophen in the percocet and stop at 4000 mg. Above that level you risk damage to your liver.
I’m sure you will find your own words to ask for what you need. Again, don’t feel guilty. If you are scolded, or treated like a child, understand that the fault lies in the person treating you that way, not in you. I wish you the best with your surgery.
bottlecappie · November 29, 2008 at 11:30 pm
That’s interesting about the high-affinity opiates. I had a kidney stone a few months after starting Suboxone…I think I was taking about 8mgs per day. At the ER they gave me IV dilaudid and much to my suprise, it worked like a charm. I didn’t tell them I was on Suboxone either – I was too scared that they would refuse to treat me and I was in agonizing pain. I guess I got lucky.
juneleaves · November 30, 2008 at 11:56 am
thanks for the information. i appreciate that you are willing to address addiction and pain management in a realistic manner. though it is scary to be treated with drugs that for many of us ultimately robbed us of our souls, sometimes it is the only alternative.
i have written you before about my concerns with addictions and chronic pain issues (fibromyalgia and migraines that are often intractable…lasting up to five days at a time.) addiction and chronic pain are a difficult combination, but unfortunately are among the many interesting cards i have been dealt in life. i have been in 12 step for 8 years now, and this past spring’s major mess that i found myself in, badly abusing my pain medication, has given me even more insight into the insidiousness and danger of my addiction.
what ha happened as a result of information you have offered on your site is
most importantly, my docs are all now communicating! i had to insist on this, none of the “one nurse conveying messages to the other,”
i feel like i am in a much better place in my overall health and well-being, as well as being able to be fully honest about my concerns addictions with my doctors, without feeling left high and dry for pain issues. i am back to using dilaudid in suppository form as needed, and yes, it takes a much higher dose than it used to, but i can abort a migraine without reverting to the ER, where they pretty much will not treat me, since i am on suboxone and they are clueless in my small college-town. ( after many years of use, triptans now make me feel like i can’t breath, not a good thing.)
i have been on suboxone since july, initially at a very high dose of 32 mg total a day (16mg am and pm) and have since tapered down to 8mg daily without any problems whatsoever. if i wake with a migraine and hold my suboxone dose it usually take 2 doses taken about 3 hours apart of 9mg (3 suppositories) to break the pain. i’ll take an anti-inflammatory in addition, which alone does nothing.
since i have been on suboxone, my fibromyalgia symptoms are much less problematic, which leaves me wondering if i should stay at the 8 mg dose, or continue to taper down? my doctor has also told me to try taking an extra 16mg of suboxone if i get a more moderate migraine to see if this works instead of the dilaudid. i tried this last night, again in combination with ibuprophen (which again, did nothing alone) and it actually broke the migraine, which i had had for a few days. it was not one of the worst, but a really nagging one, that just stagnates at like a #6 pain level, leaving me feeling pretty bad, but somewhat functional. by last night it was starting to get much worse.
is the pain relief that i apparently got from the additional suboxone psychosomatic or real? i know you mention that there is a ceiling effect from buprenorphine….
my doc recognizes that people respond differently to different medications and has given me permission to experiment with dosing to whatever level is comfortable, keeping in mind that suboxone will inhibit opiate pain relief should i need it.
overall, i am really happy being on suboxone…and for the most part, i am in a much better place physically, mentally and spiritually. i don’t want to screw it up again, but regardless don’t want to suffer in debilitating pain – which is how it used to be for me prior to pain management until i abused the very drugs that had for a short while given me the illusion of getting my life back. at least today, i have am much more accepting of the things i need to do to take care of myself, and recognize that addiction is much bigger than me!…. yet so are my headaches. 🙁
it really sucks, not only being an addict, but an alcoholic, a migraineur and a mildly bi-polar individual, but if i ignore any of these issues my quality of life slips and i become self absorbed and much sicker, despite my wishes and best intentions.
thanks for your information. i have referred all of my doctors to your site!
kara · November 30, 2008 at 2:18 pm
You are a saint (and a wonderful doctor) – thank you so much for putting my mind at ease. Hopefully, the sub doctor and/or the surgeon will cooperate knowing that it is not unprecedented to do so. Worst case, I get the percocet and combined with the phenergan I can hopefully just sleep the first couple of days. Thanks again.
SuboxDoc · November 30, 2008 at 4:41 pm
Kara, you’re way too kind! But it is gray and snowing today, the Packers lost, my kids just left to go back to New York… so I’ll take every kind word I can find!
And JM– thank you for all sharing your experiences. The whole ‘Suboxone thing’ is relatively new; I have a pretty good sense of addiction treatment with the medication, the treatment of different types of chronic pain with buprenorphine is a topic that continues to unfold, and your experiences will affect how I use the medication to treat pain in other patients. I am particularly interested in the idea of ‘breaking’ a migraine. I don’t know for certain whether your relief was psychological or physical– I see signs that there is no significant difference between 8 and 24 mg per day of Suboxone (as you noticed during your taper), but we may eventually find other effects from buprenorphine that we don’t currently know about, that had an effect in your migraine situation. For example buprenorphine does have effects at subclasses of opiate receptors besides mu receptors (just making this next part up to illustrate my point–it is almost certainly not ‘accurate’); maybe the activation of kappa receptors breaks migraine in some people. Or maybe the activation of kappa receptors breaks migraines in patients with bipolar. Or maybe only in patients with bipolar and fibromyalgia. Or maybe the combination of mu partial agonism and kappa agonism breaks migraines… or maybe buprenorphine will block migraines if taken by a female patient, in headaches that are at a ‘6/10 level’, if the headaches have gone on for three days, and if the buprenorphine is taken in the evening, after the person has been awake for at least 12 hours.
Such is our knowledge (or lack of it!) of the brain; there are so many different things going on that make every situation unique… we still don’t even know where the pain comes from with migraines. We used to have a model where the blood vessels surrounding the brain constricted, then dilated, and the dilatation caused pain… but last I read, that model was ‘out the window’ and things are more complicated than that.
I hear you with your comments about being an addict. But there are worse things… and there are times when I think that if not for addiction I would be beset by some other misery. Maybe I would be stuck as some rich anesthesiologist, sitting on a boat during my weeks off, getting some nasty sunburn, getting sick of reggae music…
As an aside, I have the movie ‘Iron Man’ playing on DVD right now. He just took off flying in his iron-man suit. That would be pretty cool…
oops– out of gas–
no– there he goes again.
Didn’t Robert Downey Jr have a number of runs through rehab? Good to see him looking healthy.
Thanks for reading and writing; more later…
kara · December 1, 2008 at 8:22 am
If this helps in your thoughts about migraines…I worried about migraines when I started the sub, since I knew it would block pain meds. However, my migraines reduced dramatically once I started it. I have only had 3 in the last 2 years. Right from the start I went from 32mg to 8mg, because I would forget to take it sometimes and found that 8mg worked just as well. So when I had my first migraine, I just took an extra 8mg when it started. It worked like a charm, to my surprise. It also worked the next 2 times, so I don’t worry about it anymore. Now here is the interesting part – I am also slightly bi-polar (I have bp2). It probably means nothing, but I thought you might find it interesting.
juneleaves · December 1, 2008 at 2:54 pm
thanks kara…i wish that were the case for me and migraines. you are soooo lucky!
interesting that you are BP2 as well (i have a history of major mania, but since I quit drinking i really am just now hypomanic if i swing up, but am usually in a state of low grade depression) i think most addicts have underlying mental and physical health problems that cause us to self medicate. for whatever reason 12 step helps a lot as well, but is not the end all be all, as I hoped it would be. have you stayed on 8mg? do you plan to taper lower, or stay at this level since it is helping?
and yes, SD,
suboxone has definitely helped with pain problems, but sadly i still get migraines no freaking matter what. i really used to beat up on myself thinking it was a mind over matter problem, that i just hadn’t found the magic equation of positive thought and good living, i’d be cured of everything. now after many years, i think that in my case, it has something do to with hormonal fluctuations and allergies. they are a predictable trigger….
but what is going on in my brain is a mystery. my aura’s are similar to an epileptic, at least similar to an epileptic friend’s symptoms. i have great trouble speaking (being a normally loquacious person, it is really obvious as i feel like my mouth won’t work and have to think hard to not slur my words) , get really weirdly weak, smell funny things and am slightly disoriented. most of the anti-seizure meds just made me really sick…
but yes, the extra suboxone really helped! i was skeptical, i took 16mg, and other than being slightly tired, it worked. many other times have i taken something and prayed and prayed that it would work, and it didn’t. my doctor wants me to try lamictal…i guess i will find out i there are any contraindications…
for now, i am finally accepting that despite my longterm sobriety from alcoholism, (and my Springtime opiate relapse which either triggered severe mania or was triggered by the opiates i was abusing -chicken or egg, I don’t know which, though i do know that I was severely depressed in March and April, from Seasonal Affective Disorder problems, and I usually get hypomanic when i come out of it, but this SPring was much much more severe.), that my body is incredibly sensitive. in every way, is just the hand of life i have been dealt.
i know some people have talked about suboxone and depression. i hate to say it, that it seems to be helping in that area as well.
i know that it this topic is controversial in recovery circles, but when the girl wrote about the idea of using suboxone and depression, i could relate. opiates didn’t open up the void in my life, so much as give me the illusion that i felt much better, but in the long run, the monkey on our backs extracts a very high price. i still know that the proverbial hole or void in my life exists, and have accepted after many years of being untreated, though technically “sober,” that even with my depression, if i don’t treat it, my recovery becomes very very rough rough and mostly about ground-level survival, rather than getting out of self and helping others.
regardless, addiction still calls a siren song, threatening to take away everything i have worked so hard to accomplish in my life these past years.
sorry for the ramble, but this is such a difficult topic for me – opiates and chronic pain. in the area in which i live, many people in 12 step feel that being in recovery means NO medication whatsoever, but I am sorry to say, that mental health issues are real, and we have the fortune in our society to be able to treat them and greatly improve the quality of our lives.
but it requires, not just the medication band-aid to be “well,” but deep introspection and hard work in other ways to expand our horizons out of the selfishness of addiction.
i just really wish at times, that i was none of the above…alcoholic, addict, bi-polar, artistically temperamental etc…wouldn’t that be nice? i know that my mind is enemy territory at times…and that recovery from addiction requires constant rigorous honesty. but life is more interesting that i every thought it would be.
hey, ya know, i think sitting on the boat after while day, listening to music would be great, for a month or so, but lets not kid ourselves. most addicts would get bored sooner or later and want to stir the pot into a state of chaos! we are crazy, creative, inspiring, terminally unique individuals who need A LOT of help on a daily basis, just to stay even somewhat sane.
kara · December 1, 2008 at 3:19 pm
Update – this is what I was told at the sub doc: You don’t need anything except the sub for pain, your tolerance is not higher, it’s lower, and sub is not addictive so you won’t have any withdrawals from it. I mentioned that I stopped taking it days ago and the withdrawals were getting harsh so this morning I had to take a crumb to feel normal. Hopefully that crumb will keep me ok until Thursday when I have the surgery. He didn’t really think I was having withdrawals from the sub, though. When I persisted about the tolerance issue, he wrote a recommendation to the surgeon. The recommendation was a Duragesic patch 100mcg for post op. When I looked this medication up, it looks like a really strong opiate and not recommended for post-op pain. So now I don’t know what to do. I’m scared something that strong might kill me. I’ve never taken anything stronger than a 10mg hydrocodone tab (granted, I took 8 of those a time…) What if I do this? I take the recommendation to the surgeon, but tell him I would prefer to try something slightly less potent first. Or should I not take the recommendation at all and just beg for mercy and threaten midnight calls (as it were)? I have a post-op appt the day after surgery, so if the med he gives me isn’t working, I’m sure he will agree to increase it at that time. Or do you think the patch is just what I need and I’m being overly concerned? And that is just assuming that the surgeon would even consider the recommendation anyway, I have a feeling he won’t. I’m sure his thought will be “if you think that’s such a great a idea, YOU prescribe it.” I’m so confused! I wished you lived around here, you would have a new patient 🙂
kara · December 1, 2008 at 4:19 pm
It looks like your doctor wants to try Lamictal. I take that for my bi-polar condition and it works wonderfully. I have no depression and no hypomania. I feel normal and it feels great!! I know it doesn’t work that well for everyone, but it’s certainly worth a try. The only issue is with your female hormones. At certain times of the month I have to raise the dose and then go back down a few days later. I’ve had a partial hysterectomy, so I really couldn’t tell you what event (menstruation, ovulation, etc.) triggers the need for an increase in the dose, but you’ll figure it out after a few months.
On the sub – I have been on 8mg for 2 years and all is well. Lately, I have tapered down to 2mg then to nothing then back up to a small crumb this morning. I think 2mg is really pushing it in my case, so when I get back on after the surgery, I will move back up to 4mg. If that goes as well as it did when I tapered down to it for a few days, I will just stay there. If not, I have no issues with staying on 8mg for the long term.
juneleaves · December 2, 2008 at 8:10 am
thanks for your response. yep, i have been recommended to have a hysterectomy by my neuro, but my OB says absolutely not. i am only 37 and many years to go with much needed, though volatile hormones, and a positive clotting factor prevents me from taking any exogenous hormones. urgh. sounds like we have some similar health issues.
but raising and lowering dosage makes sense, since our bodies are not always in a steady-state hormonal equilibrium. i have to do that with prozac and it works well, so that’s interesting that you have to do the same with Lamictal.
i would not worry too much about the post-op pain. especially if you are in the hospital. my concern has been in the past: A. having enough med to manage pain, and not freaking the doctors out by my tolerance. and B. some opiates make me manic, so I really stick with the one that does not, which is in my case, dilaudid. also, this freaks some doctors out since i refuse vicodin, percocet etc…they make me really wired. don’t worry about advocating for yourself.
we have a right to be informed about what works and what we put into our body. i find some doctors would rather us be ignorant, especially when a patient seems to “know” a lot about opiates, it must be a red flag to them. its just that i have had to use them for so freaking long that i know what works in my body and what does not. but above all, i also must be honest about my addiction and pre-disposition to medication abuse.
as long as doctors are informed well ahead of time, you have done what you can, especially being honest about past addiction issues. but it is strange that your subdoc thinks that your tolerance is lower? i was in a nasty accident about two months ago, and had to take over twice as much narcotic to cut the pain, as i had prior to going on suboxone this past July. it is an opiate blocker! i know it is a bit scary, as i worried about somehow accidentally reaching some point and over-dosing despite being for the most part functional and NOT stoned from the drugs, but it was ok. i got through the worst pain of my accident, went off the pain meds, and back onto suboxone at a lower dose than i was on before, which was great! talking about it with my support system was really important for me to stay on top of it, without going back to my old addictive ways. suboxone definitely was not enough for my dislocated shoulder, collar bone and torn AC ligament…in medicine, generally, “a patients pain is what they say it is, when they say it is.” at least in theory…
i would wait an see what happens post-surgery myself…worst case scenario is that you have some pain for a little while. i’ve never used the patch, but i would guess is that you could take it off if it is too much medication, making you feel really out of it, though i doubt you’d overdose, since they would probably have you on a lower dosing of duragesic. in my experience, addicts are really overly sensitive and frightened of pain, but so much of it is in our heads…but the SD here is right, there is no shame, and you don’t need to suffer either. just be careful for the long-run. opiates are a slippery slope, and our minds can play tricks on us thinking we are ok when we are not.
you seem to have a plan and are well prepared. good luck and i hope the surgery goes smoothly!
Mason Marsh · May 17, 2017 at 9:09 pm
Having surgery on 1 8mg of suboxone a day, no taper what to expect, help
Jeffrey Junig MD PhD · May 18, 2017 at 4:46 pm
Go to http://www.suboxsearch.com and search my blog, and the forum, for ‘surgery’. You will find tons of information, including links to the information I provide for my own patients. If your surgery is one that typically results in significant pain, you will need to have a doctor who is willing to provide analgesia. It is not DIFFICULT to provide analgesia; the doctor just needs to provide a sufficient amount of opioid agonist. But current fears about opioids has caused many doctors to run from reasoned analysis, and to instead take the position that ‘I can’t do that!’.
I usually continue a reduced dose of buprenorphine, about 4-8 mg per day, and give oxycodone, about 15 mg every 2-4 hours. That amout of oxycodone will provide analgesia without tolerance or euphoria, as long as the buprenorphine is continued the ENTIRE time.
held · November 2, 2022 at 10:26 am
Thank you very much for your knowledge I will be having surgery on my hand and have been afraid of having to go through it with no pain meds. I have been on sub. For 3 years. I’m so afraid my doctors will tell me no pain meds bc of my addiction. I will show them your articles! I had 5 teeth pulled and even the pharmacy reFused to give me the pain meds my doctor prescribed. What do I do if this becomes an issue again?
J Junig MD PhD · November 2, 2022 at 10:40 am
I hear that fear from all of my patients. For that reason, I almost always ask the surgeon to allow me to take over pain control post-op. I require three things: the request to take it over, a description of the surgery, and what would USUALLY be used, and for how long, in someone not on buprenorphine. They just fax me that info and I’m set. I usually use oxycodone after significant surgery. I ask patients to reduce their buprenorphine dose to 4 mg twice per day. Oxycodone will break through the buprenorphine in doses of 10-15 mg. Patients usually tell me that they had no euphoric effect, and it reduced pain but didn’t ‘feel’ like an opioid. I recommend sharing a couple articles with the surgeon; an old one is here, and this one is from 2020.