Surgery Preparations for a Suboxone Patient

The questions:
I am having surgery and my doc was unaware of some things and I thought that you could confirm them for him?  Could you advise him to take me off the Suboxone 10-14 days prior to surgery?  I have been researching this religously and I have come to the conclusion that it would take 2 weeks to get the Bupenepherine 100% out of my system so that there is no blockage, unless you think otherwise?  Also could you tell him about the oxycodone to keep me out of withdrawal and to help me cope with the pain?
Note:
I had also received a note from the doctor, saying that he was going to change the patient from Suboxone to Subutex before the surgery, and then back again at a later point.  This is fine, but not enough– the naloxone isn’t the problem– the buprenorphine alone is a partial agonist i.e. an antagonist at the mu receptor.  The buprenorphine alone will block other opiates, and since the patient is tolerant to the buprenorphine, it will not serve any role as an analgesic medication.  The patient needs additional opiate activity in order to have analgesia– and since his tolerance is high, he needs significant doses of a potent opiate.
My comments to the doctor:
Hi Dr. XXXX,

I don’t want to complicate your treatment of Mr. XXXX—he reads my blog about Suboxone at http://suboxonetalkzone.com where I write quite actively about my experiences treating patients for opiate dependence.  I am a (blah blah blah blah– you all know this stuff by now)

I have helped a number of patients through surgery.  The naloxone isn’t so much the problem as is the buprenorphine–  naloxone has a very short half-life and will cause a couple hours of withdrawal if injected IV, but buprenorphine is a partial agonist, and has very potent antagonism at the opiate receptor that lasts for days and days.  The half-life of buprenorphine is about three days;  when we treat addiction we are using supra-maximal doses of buprenorphine.  When I gave buprenorphine IV to treat labor pain as an anesthesiologist I would give microgram doses;  even just 8 mg is enough to block ordinary doses of opiate agonists for several days.


With my patients, or when recommending other physicians, I suggest first getting the patient to a lower dose of buprenorphine—on the order of 8 mg per day.  If you were to lower Mr. XXX’s dose tomorrow, he wouldn’t get down to a new steady-state level for at least a week or two;  he would have very little withdrawal, because the ‘ceiling effect’ occurs at a dose of about 4 mg per day, so any dose above that will have almost the same opiate activity.  From the 8 mg daily dose (usually once per day, in the morning) I stop the buprenorphine at least 3 days before surgery.  It will still be very difficult to treat post-op pain, because three days later the person will still have significant buprenorphine in his system, which has a very high affinity for the receptor.  It is important to remember that even if all of the buprenorphine was gone, the patient will still have a very high tolerance—equivalent to being tolerant to 30 mg methadone or 60 mg oxycodone.  That means that 60 mg of oxycodone only gets the patient to ‘neutral’;  higher doses are required to provide analgesia.  I usually give patients either 15 or 30 mg oxycodone tabs, to take 2 (or more) every 4 hours as needed.  At the time when the surgeon would typically stop narcotics, I change the patient back to Suboxone or Subutex—either one, as they both work the same in a person not injecting.

It is important to focus on the pain, not on the dose of narcotic. The dose is meaningless in a tolerant patient;  I have had patients require doses of morphine greater than 50 mg every 2 hours after c-section, for example.

On my blog I have a number of comments about anesthesia and surgery;  if you go to http://suboxonetalkzone.com and search for ‘anesthesia’ or ‘surgery’ you will find them.

Thanks for writing, and good luck.

Addendum for the blog readers:

I am aware that the person having surgery requested medication to prevent withdrawal; I did not mention this to the surgeon because it is a ‘touchy subject’. It is in fact illegal to prescribe or administer an opiate for the sake of treating withdrawal, with the exception of methadone clinics—and now Suboxone. For that reason, I don’t usually stop the Suboxone 10 days in advance—I stop it 3 days in advance. Most people seem to take about three days to go into withdrawal, so that usually works pretty well.

I have had a couple discussions with this writer, and I hope things work out well for him. Many doctors out there have their own ways of doing things, and most doctors consider themselves up on what they need to know; it is hard to just tell a doctor to ‘do it this way’. I know I wouldn’t like it either. Let’s all hope for a little extra consideration and sensitivity from his physician.

4 thoughts on “Surgery Preparations for a Suboxone Patient”

  1. I know this is about Suboxone, and that you are not a fan of methadone treatment–but I wonder as a former anesthesiologist, what you would recommend for a patient undergoing surgery or a very painful procedure who was on high dose methadone (say 150mgs or more)? We get a lot of questions about this on our methadone support forums and many doctors seem to have no idea how to tackle this problme, and many patients are left in agonizing pain. Is it possible to achieve adequate postop analgesia in a high dose methadone patient? Are certain drugs more likely to be helpful than others, or should the pt. simply be given higher doses of methadone? Feel free to respond privately if you don’t want to post this.
    Thanks.

    1. I am sure this is super old post but in case anyone who comes across this, i have some advice as I’ve been in this situation. After surgdry,woke up in post op hyperventilating and tears streaming ,no control ,pain worse than anything i have ever felt.
      First off,before surgery,try to go as low as possible on the methadone as fast as possible without discomfort . If i had known I was gonna have surgery I would have but it was emergency operation.
      I was on 100mg during my agonizing surgery.
      After a shot if dilaudid IV,no change. I hear nurse on phone with Dr saying nothing is working and no clue how to handle this the Dr or surgeon advised a shot of Dilaudid every 15 minutes until pain seemed to be at least tolerable.
      I’ll say this, i know its rarely used but a high dose of demerol with promethazine (phenegren) cocktail is finally what worked.
      I am pretty sure if i was given 16 to 24mg dialysis IF from the start in post op it would have worked but Dr’s are so over cautious thay I do not believe orgs an option.
      (E.g. , By the time in post op the dilaudid worked, i had been given 16 mg of dialysis but took so long as 2mg every 15 minute just took too long while in extraordinary pain.)
      Also,Dr’s consider 5mg morphine a high dose iv so thay is not an optional medocation. I know I can tolerate 60 g of just fine
      So maybe ask for the demerol phenegren cocktail and do not let them give it as 2 shots,it’s very important it’s in same mixture as the one time the nurse sit the meds,it didn’t work nearly as well,not even close.
      With the ability to use narcan if a Dr overshoot (pun here unintentional) their painkiller,thetes really no reason to be so entirely over cautious to make a patient suffer terribly.
      Fentanyl is another very good option but again,i worry a Dr most likely would be too cautious to evern bother with this med just as they do with morphine.
      Not sure why but the only med the surgeon was willing to give a large enough dude on top of my methadone was the cocktail I mentioned and hospitals today may not even have it due to its toxic nature.
      Good luck to all this on a blocking dose of methadone

      1. Thanks for sharing your experiences. I want to clarify two things– first that methadone is a pure agonist (compared to buprenorphine, which has mixed agonist/antagonist properties). Methadone doesn’t directly ‘block’ other opioids; the problem obtaining analgesia is because of the high tolerance induced by typical treatment-doses of methadone.
        Second, Demerol (meperidine or pethidine) has been largely abandoned for use in the US. It was considered a safe medication 20 years ago and still has some useful unique properties. But the drug was part of a landmark death in a NYC hospital when it was given to Libby Zion by an overworked resident. She was a patient taking an MAOI, and she was given meperidine while in restraints, causing her death from serotonin syndrome. Her death led to a law in NY State that limited resident work hours that eventually spread to similar laws across the country.
        Repeated or high doses of meperidine can also cause accumulation of normeperidine, a neurotoxic breakdown product that can cause seizures and worse.
        When I was an anesthesiologist, I found meperidine very useful in certain cases, for example when combined with a benzo for sedation during fiberoptic intubation. The drug is anticholinergic, blocking salivary glands and creating a dry airway making endoscopy easier. It also has a long ‘plateau’ to effect when given intravenously, unline opioids like fentanyl that cause a peak effect and then rapidly wear off.

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