A recent message from a reader:
What would be the ideal care-plan for the pt taking 24mg/dayof Subutex who is going in for c section? I would like to show the response tomy OB, so if there is any way, please be specific as to any tapering or substituting of another low-dose narcotic before surgery, the best med for pain control in recovery and while still in hospital, up to discharge and the best PO med course for home. I would be so appreciative and you’d really help ease my fears.
Thank you 🙂
I receive this question often, and I am confident in my ability to provide education about the issue. I have to point out that I can’t act as your doctor and give medical advice — but I’ll share my experienceafter having a number of patients on buprenorphine (i.e. Suboxone) go through a wide range of surgeries.
You can share with your doctor that I’m Board Certified in Anesthesiology, and I worked in Ors and pain clinics for ten years before leaving the field for psychiatry residency. Your doctor is more likely to believe me, knowing I have experience in that area.
I will send you a couple references about this topic, and I’ll also send my ‘Users Guide to Suboxone’. The articles provide support for the treatment I’m about to describe.
Did I mention that anyone reading this MUST use the information only to spark a discussion with his/her own doctor? Do NOT use this information on your own; doing so would be quite dangerous—not to mention illegal.
A couple basics first… The anesthetic for the surgery (in this case, a C-section) should be conducted the same as with any other patient. Spinals and epidurals work fine. Local anesthetics are not affected by Suboxone, and the spinal narcotics sometimes used play only a small role in analgesia during surgery, being more important for post-op pain.
Likewise, a general anesthetic in your case would not be affected by buprenorphine, since a narcotic-based anesthetic is not appropriate for a c-section. So we are really talking about post-op pain in this discussion.
There are two major issues when dealing with post-op or other acute pain in people on Suboxone or buprenorphine (the two medications are clinically identical; in each case, buprenorphine is the only issue, since naloxone is NOT active orally or sublingually).
The first issue is that buprenorphine is a partial agonist that acts as an antagonist at opioid receptors after surgery in the presence of narcotic pain medication. Buprenorphine is a high-affinity, long-acting medication that is VERY effective at blocking the mu opioid receptor. To deal with this first issue, you need to get your blood level of buprenorphine lower. The buprenorphine half-life is over 3 days, so it takes a week or more to make significant reductions in the blood level of buprenorphine in preparation for surgery. It is possible to treat your pain on, say, 16 mg of buprenorphine per day– but difficult, requiring very high doses of oxycodone to out-compete the buprenorphine. I have never tried treating pain in a person on 24 mg per day, but I would expect it to be even more difficult than at 16 mg per day.
I tell patients having planned surgery to taper down their dose of buprenorphine a couple weeks in advance. For someone having a C-section there is a second reason, beyond pain control, to lower the dose of buprenorphine, as doing so will also lessen the chance that the baby will have withdrawal (although I encourage people to avoid getting worked up over that issue. Studies show that ‘neonatal abstinence syndrome’ from buprenorphine is much less severe than from other opioids like heroin or methadone).
I have patients taper down to 8 mg per day or less by the time of the surgery–ideally by a week before the surgery. In my experience, most people don’t notice significant discomfort if they reduce by a quarter tab every week or two (when people stop buprenorphine, most of the withdrawal occurs when tapering off the final 2-4 mg per day). The goal is to get to 8 mg per day (or less) so that mu opioid receptors can be activated by opioid agonists like oxycodone or fentanyl.
**** It would be a mistake to try to treat your pain using ‘just buprenorphine’. Some docs apparently do that, as I occasionally receive messages from angry patients who were told they would be fine, who then go through horrendous experiences and write to me, asking me to help them sue their doctors. People on Suboxone or similar doses of buprenorphine are FULLY TOLERANT to the effects of buprenorphine, and because of the ceiling effect, higher doses of buprenorphine will provide NO significant pain relief.
As for the second issue, even if we could magically remove all of the buprenorphine in a patient’s system on the day of surgery (we can’t), the person would still have a high opioid tolerance—and so would require high doses of opioids to treat pain. There is debate over the exact tolerance, but in my experience people on buprenorphine have a tolerance similar to someone taking 60 mg of oxycodone per day, or 40 mg of methadone per day. That means that even if we could remove all of the buprenorphine, it takes 60 mg of oxycodone (or equivalent) just to break even, before providing pain relief. Since buprenorphine will be in the system, it takes more than 60 mg– but 60 mg is the starting point.
With that in mind, I generally try to give people the equivalent of 60 mg of oxycodone per day, and provide more oxycodone ‘as needed’. One way is to give Oxycontin, 20 mg three times per day, and then use oxycodone 15 mg every 4 hours as needed. Another way is to avoid the Oxycontin, and give oxycodone, 15-30 mg every 4 hours as needed.
**** Oxycodone is a 4 hour medication. Some doctors make the mistake of thinking that since they are giving higher doses, they can give it less often. Again, their patients write to me afterward to complain. Oxycodone is metabolized at the same, fast rate in people on buprenorphine as in everybody else, and has little effect beyond 4 hours.
**** Some docs fear respiratory depression from using high doses of opioids, and would rather just let the person suffer than carefully think through the issue. I’ve even heard about docs telling patients ‘there is nothing that can be done for your pain’. That is nonsense; pain relief CAN be provided, but it takes high doses of narcotic to do so, and THAT requires some extra planning. If they need to put you in the ICU to feel comfortable, so be it– you deserve pain relief.
For doctors: because of the long half-life of buprenorphine, ‘renarcotization’ is not an issue. (that situation can occur with short-acting antagonists like naloxone, when a patient receives long-acting pain medication… and then the blocker wears off, leaving the patient vulnerable to respiratory depression).
Buprenorphine easily outlasts any agonist, so a patient is not going to suddenly overdose. In fact, people on buprenorphine are protected to some extent from overdose; deaths on Suboxone occur when a person with a low or no opioid tolerance takes Suboxone, usually combined with a second respiratory depressant like alprazolam. People on buprenorphine usually report getting pain relief from 15-30 mg of oxycodone, but not ‘feeling’ the drug in any other way. They feel no euphoria or sedation– but they get pain relief. I’ve written about the benefits of the combination for treating severe chronic pain but that’s another issue….
Typically, XXXXXXX, I tell my patients to taper to one tab of buprenorphine or Suboxone per day by a week before surgery. Starting the day before surgery, I have them take a half tab of buprenorphine or Suboxone per day– and continue that on the day of surgery, and throughout the post-op period. Why continue it? Because with the long half-life, it will be there anyway– and I feel better having some idea how MUCH is there. There are benefits to continuing it as well, such as preventing euphoria from opioid agonists, and making it easier to restart the full dose of buprenorphine later– without the need to go through 24 hours of withdrawal to avoid precipitated withdrawal.
I would have the surgeons do the surgery as they always do, using general, spinal, or epidural. For post-op, I usually recommend using PCA (patient controlled analgesia) with fentanyl; there are some anecdotal reports that fentanyl competes more effectively with buprenorphine than morphine (which would make sense, since fentanyl has much higher affinity). I suggest that they forget numbers, and set the PCA for at least twice what they normally would use, pay close attention to your respiratory rate, pulse-ox, and PAIN, and increase the dose QUICKLY if necessary.
As soon as you are taking oral meds, things become much easier. I usually recommend the medications listed above– i.e. 15-30 mg of oxycodone every 4 hours. I sometimes use a ‘basal narcotic’ like oxycodone, and dose on top of that as mentioned above.
When you no longer need opioid pain relief, stop taking oxycodone for at least a few hours, and then resume your full dose of buprenorphine. NOTE– I have not had a patient get precipitated withdrawal, provided they continue at least 4 mg of buprenorphine every day throughout the post-op period. But I cannot guarantee that it won’t happen.
The safest thing is to stop the oxycodone for longer than 4 hours– for as long as possible, until you actually feel withdrawal– and THEN restart buprenorphine.
I have to stop at this point– I will send those articles when I’m at work tomorrow. Good luck with your new baby!
Stacey · January 13, 2018 at 10:59 pm
Wondering if your last paragraph would be the same for someone on a much lower dose throughout the pregnancy continuing that small dose throughout delivery and post partum or post-op. I have tapered to just under 1mg suboxone. I planned to continue my normal dose throughout the labor process regardless of how my pitocen progresses and any addl pain relief I receive. I just want to make sure this would have the same effect in regards to avoiding precipitated w/D’s . My Drs are not aware of the bupe.
Jeffrey Junig MD PhD · January 23, 2018 at 4:02 pm
Studies do not show a dose effect, but I have to believe that the incidence is lower in cases like yours. Good luck!
Raychal Richardville · February 22, 2018 at 4:30 pm
I am on 6my of subutex per day and 8 months pregnant. My concern is my psychiatrist who gives me the subutex is telling me that when I go to have my csection, he is just going to increase my subutex and boy allow my OB to give me any narcotics while recovering. Then he is going to switch me from subutex to suboxone once I have come home from the hospital. I have MAJOR concerns on both of these. My OB said there is NO way she will let me be in pain and that subutex will NOT give me enough pain relief from the csection. So I think she will be able to keep me comfortable while I’m in the hospital, regardless of what the psychiatrist says. My concern with switching to suboxone is that I would like to wean off subutex as soon as I have the baby. I have heard it is a lot harder to wean off suboxone vs subutex. I am recovering from being a 5year I.v. heroin addict. I don’t want to push myself to hard, and end up relapsing…but I don’t want to end up on suboxone long term either. Also, I’m nervous that child protective services, will come to hospital and test.the babies meconium for heroin, I was told by CPS, that they can come do that and the test goes back to the first trimester and if it’s positive for heroin, they will take the baby. I didn’t know I was pregnant until I was almost 14 weeks and I checked into this program to detox at 15 1/2 weeks…So I got help as soon as I could, so why would they take the baby from someone who is following a program, and doing well? Any suggestions?
Jeffrey Junig MD PhD · March 19, 2018 at 7:09 pm
I’m sorry for the delay– I can’t imagine CPS taking a baby away when a person is doing the right thing and addressing her addiction. Feel free to email me at the address on my web site, fdlsuboxone.com, if I can be of any help explaining why people on buprenorphine are not impaired. And actually the same reason is why buprenorphine does NOT work for post-surgical pain, no matter the dose…. because patients are already on the ‘ceiling dose’ and full tolerance develops the opioid effects of the medication. A person on buprenorphine cannot get ‘high’, and cannot get significant pain relief, because additional doses have no additional effect.
I hope things worked out?
Raychal · April 8, 2018 at 7:10 pm
Hi. Update for you…I delivered my baby boy at, 36 weeks, in March 16. He was sent to NICU due to breathing difficulties, because he was early. He spent a week there. The NICU staff needs to be educated on what a baby with withdraws actually acts like…they kept referring to a paper with symptoms listed…symptoms that also were due to a babypaper being early. The main defense I had, to avoid them giving him methadone, was he was consolable. Any time he was upset, there was a reason, they had him naked and freezing…waking him up from his sleep bc his alarm was wonky, etc. Anyway I worked closely with nurses bad the doctor day and night, to ensure he was getting better, and to get them to not give him methadone for nothe reason. When the doctor released him, DCS, who had interviewed me a day or two prior, came back and informed me theythat were taking him. They said it was because I was honest about my use of heroin while pregnant, even though I had no clue I was, and they assumed his cord.blood drug screen would be positive. His test results came back 30 min later…NEGATIVE for any drugs, only positive for the subutex I was prescribed. The DCS worker was informed immediately, yet she said it was Friday and she wouldn’t be able to get in front of a judue (it was 11am) and I was recently informed by three different caseworkers from DCS, that she could have stopped the whole thing right then, but since she had. A chip on her shoulder, she continued. So here I am, baby is three weeks old…healthy…clean …trying to nurse (milk won’t come in fully bc I don’t have him at night and can’t nurse) I have never failed a drug screen, I’m very involved in my treatment, counseling etc. The judge said the treatment I was.currently doing, didn’t test me random enough, and that I would probably start using again. This has been a complete disaster. Our entire community needs education. Subutex saved my life…my child’s life…he had NO WITHDRAWS AND TESTED NEGATIVE. all the nurses and doctors in the NICU were impressed by my knowledge, my love for my child, and.my strength for overcoming my addiction. They said “if all mom’s in recovery were like you and here with their babies every second…things would be much better.” They were all shocked with the decision of DCS. No one understands WHY…why punish me to this horrid extent for doing the right thing…and doing well in treatment? Final court date is the 23rd. I.do NOT deserve this. I pray no one else has to go through this, after overcoming addiction…and dealing with all the ridicule that comes with it. I VOW to make a change…I’m going back to school this fall to get my drug counseling degree. We have to educate these people, to understand that these.medical assisted recovery programs WORK!! It’s well.worth the funding…and if they push people like they have me, they will cause people to end up relapsing or worse…suicide. They completely broke me…my heart was ripped out. I sob terribly every time I have to leave my beautiful baby boy. What if I wasn’t this strong? What if I didn’t want to change things and help other people
Get well and recover? DCS system is A complete JOKE
Jeffrey Junig MD PhD · April 8, 2018 at 7:40 pm
Wow- that’s horrible. I used to see that type of thing in my area, but things are slowly getting better. I encourage you to follow your passion, because we need passionate people to change minds. I try to get in front of the community every chance I get; I am doing a talk to my community next week and hopefully county workers will show up, since we work with the same people. I’m sorry about what you’re going through.