Opioid Analgesia Without Addiction

I don’t have pull with the addiction-related organizations out there. I’m never been a joiner, and I tend to notice the problems caused by medical societies over the good things that they supposedly accomplish. For example PROP, or ‘Physicians for Responsible Opioid Prescribing’, have a specific mission. Once a group has a mission, any considerations about individual patients go out the window. PROP has propagated the message that opioids are NEVER beneficial for patients with chronic pain.

Legislators with no knowledge of clinical medicine hear that message, and respond by passing draconian laws that interfere with any considerations of individual patients. I would guess that the people of PROP pat themselves on the back for encouraging laws that remove physician autonomy. I’m sure they figure that they are smarter than all the family practice docs out there. But in reality, they are only destroying the control of doctors over patient care, and handing that care over to politicians. Way to go, PROP.

In the same way, the societies that hold meetings about meetings, that elect Secretaries who become Vice Presidents who become Presidents, get to publish the articles that describe clinical protocols. The doc who spends every day talking with patients has no access to these sources, and little ability to influence those protocols. Sometimes the societies and organizations get things right… and sometimes they get things wrong. The latter is the case with post-op pain control in patients on buprenorphine products.

I’ve written about this before, as regular readers know. Over the past 8 years I’ve had dozens, if not hundreds, of patients on buprenorphine undergo surgery. The surgeries include coronary bypass, thoracotomy, rotator cuff repair, C-section, nephrectomy, total knee or hip replacement… and a host of minor surgeries with scopes and lasers. I’ve treated these patients in a number of ways, in part because hospitals that provide emergency care have different ways of dealing with post-op analgesia. I rarely have control over what they do acutely– but I almost-always take over pain control when patients are discharged.

In the past few months there have been several ‘articles’ stating that the best way to handle surgery, in people on buprenorphine products, is to stop the buprenorphine before surgery, and treat pain using opioid agonists. This opinion is not supported by any data. It is someone’s opinion– usually someone who has a title, i.e. someone who spends at least some of his/her time in society meetings. That time is removed from the amount of time that could be spent treating and speaking with patients. Frankly, the ‘higher’ a doctor is in society circles, the less time they spend in patient care. That comment will anger the docs who it applies to. I can hear them now– saying I’m only full of ‘sour grapes’. But maybe those same docs should look in the mirror, and wonder how they ended up as ‘President’ of a society.

I’ve used the approach claimed as best practice in the society journals– i.e stopping buprenorphine before surgery– and the same thing always happens. Tolerance to opioid agonists rises very rapidly in the post-op period. Patients are discharged on huge doses of opioid agonists. And at some point, agonists must be discontinued for 24 hours to allow for re-induction with buprenorphine agents. I’ve had several recent patients go through this exact process– and my frustration motivates this post. One guy shot himself in the femur, and the bullet also passed through his lower leg. He needed fasciotomy to avoid losing the leg. His Suboxone was discontinued at admission, and ten days later he was discharged on 30 mg of oxycodone every 2-3 hours– i.e. over 200 mg per day. The other person was in a serious car accident, and had multiple fractures— femur, pelvis, ribs, wrist– as well as internal injuries. After 3 weeks he was released on over 300 mg of oxycodone per day!

On the other hand, I’ve had many patients go through the surgeries listed earlier while maintained on buprenorphine, 4-8 mg per day. In ALL cases, they had excellent analgesia with lower doses of oxycodone than in the people who stopped buprenorphine. Most patients did well on 15 mg of oxycodone every 3-4 hours– a max of 120 mg of oxycodone per day. In a few cases– i.e. in the most painful operations, in the most sensitive patients– I had to use 30 mg of oxycodone every 4 hours.

The most amazing thing about the combination of buprenorphine and opioid agonists is the absence of tolerance to agonists, when buprenorphine is present. I’ve had patients with recurrent injuries that required repeated surgeries, including a woman who tore her rotator cuff and the surgical repair THREE times over three months. She took the same amount of opioid agonist for three months, with no noticeable decrease in efficacy. After the final operation, after three months on significant amounts of opioid agonist, she simply stopped the agonist and resumed her full dose (16 mg) of buprenorphine. She had no withdrawal, and not other complications. She simply stopped the agonist and resumed buprenorphine treatment.

I’ve come to realize that buprenorphine effectively ‘anchors’ tolerance when patients take opioid agonists, as long as the buprenorphine is continued. Patients always say the same thing: that the pain was reduced by the agonist, but that it didn’t ‘feel’ like the agonist they used to take. In fact, patients who could never control pain pills found that they COULD control agonists if they stayed on buprenorphine.

A couple years ago I presented these findings at an annual meeting of ASAM. The slides can be found here. I believe that some day, combinations of buprenorphine and opioid agonists will be the standard approach to pain treatment. The combination allows for opioid analgesia without tolerance, without euphoria, and with little or no risk of addiction. If THAT doesn’t piqué your interest, you have no business reading about opioid dependence!

I picture combinations of buprenorphine and fentanyl… especially since both are now FDA-approved as transdermal patches. Or perhaps a combination of fentanyl lozenges and sublingual buprenorphine. The possibilities are endless. Throughout history, the miracle of opioid analgesia has been cursed by the attachment to tolerance, dependence, and addiction.

Imagine if that curse was lifted from opioid analgesia. Can you even dare to imagine that world? I’m telling you… it is closer than you think—- and there for the taking.

Suboxone Patient Needs Surgery, Refused Pain Control

First Posted 10/21/2013
I have received MANY messages over the years from patients on buprenorphine/naloxone (Suboxone) who required surgery, but whose doctors refused to provide post-op analgesia.  Those of you not on Suboxone– can you imagine having surgery, and being told that ‘it is too much hassle to give you any medicine for pain relief’?
Below is a comment to my last post, followed by my suggestion.  I am usually not a fan of getting medical boards stirred up over other doctors’ business, but this type of situation is RIDICULOUS, and must be stopped.
The comment:
I’m scared to death!!  I have been on Suboxone for over a year.  Previous to  that, I was on it for a couple of years before stopping its use.  At that time I  developed some gall stones and presented to the ER in pain I can not even begin  to explain.  Ultimately the stone passed but I need to have the gall bladder  removed.  I figured this was a good time to maybe get off of Suboxone.  I knew I  would be getting some standard opiates after surgery to manage pain so I thought  it could manage the Suboxone withdrawal as well.
It was an awful experience and I eventually resumed Suboxone.  It has been a  little over a year now back on.  About 8-12 mg/day.  So about a couple of months  ago, I needed shoulder surgery.  Here we go again.  I tapered back on the sub  and went through with the labrum repair.   I did discuss it with my  psychiatrist but he basically said he wanted NOTHING to do with the acute  pain management portion of this surgery.  And I actually experienced very little  pain post-surgery and went almost immediately back on  sub.
Now I have had complications mainly from scar tissue.  Tremendous pain.  My  ortho recommended a surgical manipulation to clean out the scar tissue.  So I  went along and although the post surgical pain was much worse this time, I got  through it OK and back on sub.  Now I need to to go back to my psychiatrist for  a refill on the sub.  But, because I did not discuss THIS event with him (I  already knew he didn’t want anything to do with it) he said he would not refill  or treat me anymore.  So now I am one year in on Suboxone and being told to take  a flying you know what because of surgery I needed.  I just feel that if I’m on  Suboxone, I am at the mercy of whomever is treating me.  It is like blackmail.  
My response:
Shoulder surgery can be one of the most painful operations to endure.  If patients have inadequate pain relief after surgery, they risk developing scar tissue formation because of inadequate movement and physical therapy.  In other words, you second shoulder surgery might have been required BECAUSE you didn’t get pain meds after the first surgery.
Even if that is not exactly the case, people on Suboxone deserve pain relief after surgery.  Can any of you non-Suboxone patients imagine having a surgeon say ‘you will need pain meds after surgery, but it is too much hassle so I’m not going to give you any’?
I suggest sending a letter to your medical licensing board and saying something like this:
I am prescribed buprenorphine/naloxone, an FDA-indicated treatment for opioid dependence, by Dr. Whatever.   That doctor is certified to prescribe buprenorphine and Suboxone, and so should be aware of the proper way to treat post-operative pain in patients on that medication (as described inthis article).  I realize that there is a certain stigma for addiction even for those of us trying to do the right thing with appropriate medication— but refusing to treat post-operative pain is not consistent with the Hippocratic Oath.  Because my doctor simply refused to ‘get involved’ with treating my surgical pain, I was forced to endure the pain of surgery without any significant postoperative pain control– a level of care that would not be tolerate even for a family pet.   I wish to speak to someone at the board about the postoperative care that I did not receive.
Will it help?  I have no idea.  But the ONLY way things will change is if enough people start to complain.  Good luck.

Taking Buprenorphine, Having Surgery

Originally Posted 8/12/2013
I will get to ‘Part II’, but today I talked with a patient about something that happens too often, that deserves to be pointed out.  The person was in the ER with an injury that resulted in tib/fib francture.  The ER doc provided no analgesia, in the ER or at discharge, telling the patient “you would get sick if I gave you pain medicine because you are on Suboxone.”
I have a few paragraphs typed up that I send to dentists, surgeons, and other physicians when a patient on buprenorphine has a painful procedure.  I am pasting it below so that it can be copied, printed, and given to physicians to encourage them to do a bit of continuing medical education on the topic.  Those of you who are already enlightened, please leave comments if you see something that you would change.   I have literature to back up this type of approach;  send me an email if you’d like the reference.
Painful Procedures and Buprenorphine Patients
Buprenorphine is a partial opioid agonist that is used for several indications.  In low doses—less than 1 mg/day—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 or impossible 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 (including myself) 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 say that opioid agonists relieve pain if taken in sufficient dosage, but the subjective experience is different, in that there is less ‘euphoria.’
Important points:
Patients on daily maintenance doses of buprenorphine do NOT receive surgical analgesia from buprenorphine alone, as they are 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.
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 precipitate 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. Note that Ultram has opioid and non-opioid effects; the opioid effects are blocked by buprenorphine.
I have had success in people taking 4 mg of buprenorphine/day, using oxycodone, 15-30 mg every 4 hours.  Some patients can control their own intake of oxycodone while on buprenorphine, but some patients CAN’T.  Overdose IS possible, if patients take excessive amounts of the opioid agonist. Consider providing multiple prescriptions with ‘fill after’ dates, each for a very short period of time (e.g. 2 days each) to that patients do not have access to large amounts of opioids at one time.
For longer post-operative periods I have used combinations of long and short-duration agonists, e.g. Oxycontin 20 mg BID plus oxycodone, 15 mg q4 hours PRN.
The risk of death is significant for opioid addicts not on buprenorphine.  Buprenorphine/Suboxone has opioid-blocking effects that reduce risk of overdose and death.  Asking a person to stop or ‘hold’ their Suboxone is introducing significant risk of injury.  Opioid addicts are NOT generally able to stop Suboxone without replacing it with illicit opioids.
J Junig MD PhD

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!
FYI: E-mail me for a free copy of my ‘User’s Guide to Suboxone’ and for the reference described above.

Medical bias against addiction

I haven’t gone anywhere in case you’re wondering… but I recently started writing a blog on Psych Central, called ‘an epidemic of addiction.’ Please add it to your reading list! This is my favorite time of year and the time I am most likely going to be outdoors, so watch for posts to pick up a bit as things get colder outside.
I’m probably in the wrong state of mind to be blogging, so consider this more along the line of venting. I had an encounter with a local physician a couple days ago that left me shaing my head– I have a solo practice so I have forgotten just how misguided medicine can sometimes be. I was asked to speak with an orthopedist for a patient who takes buprenorphine, who was having major knee surgery. The orthopod started the discussion by saying that he is angry that the patient didn’t say at their first meeting that he takes Suboxone– like it should have been spelled out on his forehead, to make certain that he didn’t give the patient some undeserved pat on the back or some measure of kindness. I explained that people on buprenorphine find often find that they are treated differently by (ahem) those doctors out there who (AHEM) pre-judge people… And the ortho guy said ‘well, for good reason!’ As I remember the encounter I’m having visions of the song ‘KILL THE BEAST!’ from Beauty and the Beast– I’m sure this particular doc wishes we ALL would just go away…

Is addiction treated like a disease?

Where was I? Oh yes– the doc then explained to me just how hard it is for him to treat people on Suboxone. He explained how the ‘therapeutic window’ is narrower– meaning that the ratio of the dose that treats to the dose that kills is larger. I tried to explain that it ISN’T– the entire window is HIGHER, but not NARROWER. You all know that, of course– on buprenorphine your tolerance goes up, and it takes a much larger dose of opioid to get pain relief, and a much, much, much larger dose of opioid to cause death. I tried to explain that this is not rocket science; I would taper the person off buprenorphine ahead of time (I usually tell people to take 4 mg of buprenorphine per day for a week before the surgery, then skip it entirely on the day of surgery), and he could simply treat the person as he would anyone who is tolerant to about 60 mg of oxycodone per day. I still cannot believe the response from him–that ‘nobody around here takes that much oxycodone’– that those are ‘big city problems’ and that there just aren’t people doing that around here.
He told me that he doesn’t like giving pain pills to ‘these people’ (he knows, by the way, that I am an opioid addict). Never mind that he is going to be doing a ‘total knee’, where the ends of the femur and tibia are sawed off and replaced with metal pieces. I explained that proper treatment is to provide a basal amount of narcotic, and then use a larger than normal PCA (patient controlled analgesia) deamand dose. I explained that fentanyl may work better according to some reports, but he said ‘I never use fentanyl.’ So I explained that he could use morphine, but that it would take at least 5 – 10 mg IV to have ANY effect on pain. He said that he would never give that much– that he would give less than usual, if anything.
At some point he mentioned that it bothered him that the patient has taken buprenorphine for 8 months– that it bothered him to ‘think that there are people out there walking around on that stuff.’ I told him that in some states, the more progressive and intelligent licensing boards are recognizing that patents on buprenorphine are not impaired, and are treating them like regular people– to which he replied ‘then why don’t we just give alcoholic pilots a 12-pack and let them fly?!’
Wow. I had a range of feelings after the discussion. The first thing I did was contact the patient and strongly recommend that he seek surgery elsewhere. The guy I am talking about is good enough at sawing bones, but is clearly an idiot when it comes to thinking through medical challenges– and my patient deserves to know that. In a perfect world, someone would recognize that doctors like this one have no business working in the field of medicine. I used to work with this doc when I was an anesthesiologist and I knew that he was bone-headed (pun intended!), but I had forgotten just how nasty and judgmental he could be. I am tempted to post his name, but I won’t — it would only bring me even more headaches than I already create for myself! But if anyone is having orthopedic surgery in Northeast WI, feel free to send me an e-mail and ask.
The main thing I’d like to say though is that I am sorry that the medical profession has those types of people among its memebers. Those of you who feel like you are suddenly being judged, when your doc finds out that you have struggled with addiction– you are probably NOT going crazy. Ignorance is alive and well, and the day when addiction is treated like other diseases is still a long ways off. And that is a real shame.