Suboxone, Pregnancy, C-Section, and Surgery

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 🙂

My Answer:

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!