Post-Operative Pain in Suboxone Patients

Originally posted 12/19/2012

I’ve written about this topic a number of times, but I continue to receive emails from people on buprenorphine who describe inadequate pain control following surgery.  I have prepared a document for my own patients to provide to surgeons, dentists, and ER staff to be used in the case of injury or surgery.  A copy of that document can be found below, or can be downloaded here.

As with any of my comments, the information below must be used in consultation with your OWN buprenorphine-certified physician.  Feel free to use my comments as a starting point for discussions about upcoming surgery or dental work.   But do NOT use the information to treat yourself, for example using medication or substances that were not prescribed for you.  Taking opioid agonists while treated with buprenorphine requires careful consideration, as the risks of opioid use include respiratory and cardiac arrest (i.e. death).

Re:  Surgery in Patients on Buprenorphine

Buprenorphine is a partial opioid agonist that is used for several indications.  In low doses—less than 1 mg—buprenorphine is used to treat pain (e.g. Butrans transdermal buprenorphine).  In higher doses i.e. 4 – 24 mg per day, buprenorphine is used as a long-term treatment for opioid dependence and less often for pain management.  At those higher doses, Buprenorphine has a unique ‘ceiling effect’ that reduces cravings and prevents dose escalation.  Patients taking higher dose of buprenorphine, trade name Suboxone or Subutex, become tolerant to the effects of opioids, and require special consideration during surgical procedures or when treated for painful medical conditions.

There are two hurdles to providing effective analgesia for patients taking buprenorphine:  1. the high opioid tolerance of these individuals, and 2. the opioid-blocking actions of buprenorphine.  The first can be overcome by using a sufficient dose of opioid agonist, on the order of 60 mg per day of oxycodone-equivalents or more.  The second can be handled by either stopping the buprenorphine a couple weeks before agonists are required, something that most patients on the medication find very difficult to do, or by reducing the dose of buprenorphine to 4-8 mg per day, starting the day before surgery and continuing through the post-op period.  Given the long half-life of buprenorphine, it is difficult to know exactly how much remains in the body after ‘holding’ the medication.  That fact, along with the difficulty patients have in stopping the medication, leads some physicians to use the latter approach: i.e. to continue 4 mg of buprenorphine per day throughout the postoperative period.  People taking 4-8 mg of daily buprenorphine report that opioid agonists relieve pain if taken in sufficient dosage, but the subjective experience is different, in that there is no feeling of euphoria.

• Patients on daily maintenance doses of buprenorphine do NOT receive surgical analgesia from additional medication, as they are completely tolerant to the mu-opioid effects of buprenorphine.
• The naloxone in Suboxone does not reach the bloodstream in significant amounts, and has no relevance to the issue of post-operative pain and Suboxone/buprenorphine.
• Sudden discontinuation of high dose buprenorphine/Suboxone results in opioid withdrawal symptoms within 24-48 hours, similar to the discontinuation of methadone 40 mg/day.
• Normal amounts of opioid pain medication are NOT sufficient for treating pain in people on buprenorphine maintenance.
• Opioid agonists will NOT cause withdrawal in people taking buprenorphine.  Initiating buprenorphine WILL cause withdrawal in someone tolerant to opioid agonists, unless the person is in opioid withdrawal before initiating buprenorphine.
• Non-narcotic pain relievers CAN and should be used for pain whenever possible in people on buprenorphine to reduce need for opioids.
• Patients experiencing weeks of opioid withdrawal from discontinuation of buprenorphine are NOT good surgical candidates, as they are usually depressed, sleep-deprived, malnourished, and dehydrated.

For more information, I may be reached by email: drj@fdlpsych.com