Acute pain e.g. surgery while taking Suboxone

From a patient looking at having surgery:
I’ve been on Suboxone sucessfully for three full years, after ten years on everything up to 100mg fentanyl patches every 48 hours for chronic pain. However, it doesn’t work for acute pain, like having teeth pulled. I’ve been on Lortab 10/650 tabs briefly (1 week) twice in that three years. Pain was not suppressed adequately because of the suboxone. These were painful and no notice extractions. I now know I will lose 7 teeth for dentures in about 10 days. I can cut back on suboxone use (currently 8mg x 2 a day), but without a month or so cannot decrease to the point of total elimination. What level of pain medication will make me comfortable during the 3 to 4 days of initial oral surgical pain and how in the world do I get a dentist / doctor to understand my situation and concern. “Obviously I taking Suboxone because I am an addict and am just asking for drugs” right?
The two times I used Lortab as stated above, I started feeling withdrawl symptoms after just a couple days without any suboxone. My life works on Suboxone, no cravings, much less pain, a lot less burning, exercise daily. I no longer take antidepressants and feel like I can make it, even with the degree of pain I still have. I just have to be carefull and not over do it. Is this all just unecessary worry, or is there something realistic I can do?
Sincerely,
XXXX

My Response:
Surgery is a tough situation for Suboxone patients. I have had a number of patients go through surgery for one thing or another and have settled on the following procedure: if the person is not having significant pain and needs elective surgery, I have them stop the suboxone three days before the surgery, and I give them clonidine and ativan to help with the withdrawal they will have on the second or third day without suboxone. After the surgery they will still be partially blocked, and even those who are not blocked will have a high tolerance, so I usually augment their pain control. I will add to the opiate agonists that they need after surgery, and stop the augmentation at the point where the surgeon usually stops narcotics– my rationale is that a higher dose is needed, but a longer period of time should not be needed.
If a person has a condition that is causing an increase in pain and that also requires surgery, such as an abscessed tooth, I will do the same but instead of giving clonidine and ativan I will give an opiate of some type to treat the pain. It usually takes high doses, as the person is highly blocked for the first couple days off Suboxone.
The problem from my perspective is that I cannot give a bunch of methadone or oxycodone to a person who has ‘street connections’ unless I trust the person absolutely. Every person who has had problems with opiates, myself included, should recognize and acknowledge that the situation is a dangerous one– if I have a patient say ‘what, you don’t trust me?’ red flags go up! Of course I don’t trust you!! I don’t even trust myself!!
Unfortunately, there is tremendous social stigma against addiction and against people who ‘look like addicts’ for one reason or another– and I feel for you, because yes, you will be ‘judged’ by your doctor. The thing that really stinks is that if a person tells their surgeon the truth, explaining why they need more narcotic than usual, the surgeon often responds by giving less narcotic— or giving none at all!! So I have to step in for my patients and try to help as best I can. I cannot do the same for people I don’t know, even though I recognize the tough spot they are in– if I started trying to treat pain in people I hardly knew I would quickly lose my license, and that wouldn’t help anybody.
I would hope that any doc prescribing Suboxone would recognize the tough spot that patients on Suboxone are in when it comes to surgery, and would help them during that period of time. The medication (Suboxone) that the doc is providing you has problems that come with it– namely the blockade that occurs when a real narcotic is needed– and that problem falls squarely on the shoulders of the doc who prescribes Suboxone. At least it should fall there– there are docs who seem to have no shoulders… and shame on them!
I hope your doc will help–there are good docs out there, and the tricky thing is finding them. Thanks for reading and for your question.
SD
PS:  I will add one more thing…  most people take about 16 mg of Suboxone per day to get maximum relief from opiate cravings.  If taken correctly, doses much lower will easily provide full block of their opiate receptors.  The possible need for surgery is the main reason for taking lower doses of Suboxone– because of the ceiling effect there is no real difference in the tolerance level for people on different doses of Suboxone, but the people on lower doses have less buprenorphine in their system and so require less narcotic to overcome the block of their receptors.  The decision over proper dose involves balancing that issue, the cost issue, the amount of cravings, etc to arrive at the proper dose for an individual patient.