Thanksgiving and Suboxone… Is My Surgeon A Turkey?

Thanks to Mike for this question:
I’m having surgery the day before Thanksgiving.I take 24-32mg a day for the past year,and I’m a little worried about surgery.I told my surgeon I take suboxone and I’m a recovering addict,and I don’t take pain medication. But he told me he will treat me as a normal patient,and with that percribed me 60 percocets. I went to my pharmacist and talked to her about it,she called the doctor and he called me back to his ofice, I told him I was concerned about the 60 percocets he gave me,his reponse was again “I’m going to treat you as a normal patient” what ever that means? Anyway I did’nt fill original perscription,so he gave me a new one, 40 percocets,hmmmm. Anyway NO one in my family know’s I take suboxone,and they also don’t think I have a perscription for painkillers,my problem(other then lying about the two medications) is the day of surgery,and the fact that I have a doctor who does’nt understand addiction.I know I will be given fentynol,I stopped taking the suboxone two days agos’which will give me 3 days to get the suboxone out of my system,will that be enough time,considering my daily dose?
My Response:
That is a fairly high daily dose of Suboxone;  R-B sent out a mailing a few months ago setting (or ‘resetting’) their recommended dose range, taking into account the current problems with diversion of Suboxone onto the street.  I often say to patients that ‘the main problem with taking such a high dose, other than the waste of money, is that if you ever needed surgery it would be very difficult to overcome the block from that much buprenorphine’.  So I am glad that you will be off the Suboxone for several days.  Even after 3 days you will still have a significant amount of Suboxone;  the half-life is about three days, so if you took your last dose of 32 mg three days ago, you would have the same amount of buprenorphine in your body as a person who took 16 mg this morning.
I have one patient who had emergency surgery a few hours after her morning dose of 16 mg of Subutex (she had a C-Section).  The surgery went fine– she had a spinal, but as I have mentioned here before there is no significant problem with anesthesia, whether it be by epidural, spinal, or general.  For procedures on the lower extremities or abdomen an epidural is ideal, as then the catheter can be used for providing analgesia post-op by infusing a low concentration of bupivicaine or another local anesthetic. If an epidural isn’t an option, the main problem with surgery on Suboxone is controlling the post-op pain.  My patient with the C-Section had to go to the ICU– they weren’t comfortable on the ward–to get morphine every couple hours, in doses as high as 30+ mg.
I’m a little confused, Michael, by the conversation between you and your surgeon. I’m not certain what you meant when you went back and said you were concerned about the 60 percocets– were you concerned that there were so many, or that there weren’t enough? 60 percocets may be too few or too many, depending on the nature of the surgery and the size of the percocets.  One thing that isn’t relevant, that many people get confused over, is your dose of Suboxone– at least from the perspective of your tolerance.  Because of the ceiling effect, your tolerance will by the same, whether you take 8 mg Suboxone or 32 mg Suboxone.  Of course, the residual Suboxone in your system will be higher from the higher dose, and so you will need more post-op medication taking that into account.
First, though, I’d like to point out something that is the result of ‘stigma’.  Your surgeon said and did something that is unfortunately quite common when he said he would ‘treat you like a normal patient’.  On the surface, and from the surgeon’s perspective, that sounds quite big of him;  he isn’t going to punish you for being a ‘scum-of-the-earth-drug-addict’– he is going to act as if you are a genuine human being!  Gee, thanks, Doc!  I admit I don’t know what is in his head– is he thinking ‘I won’t discriminate against him’, or is he thinking, ‘I’m not going to fall for some addict story about increased tolerance!’  I don’t know which– but in either case, he is making a mistake:  You’re NOT a normal patient!  If you were three years old, would he treat you like a ‘normal adult patient’?  If you had severe respiratory disease or a head injury would he treat you ‘like a normal patient’?  And if you had cancer, and had been taking high-dose narcotics for six months, would he treat you like a ‘normal patient’?  Here is where I should say: THIS REALLY MAKES ME SICK!!
You have two reasons to need higher doses of pain medications post-op: residual buprenorphine in your system, and high tolerance.  Even if the buprenorphine is completely gone, your tolerance is such that it will take about 60 mg of oxycodone every 6-8 hours just to ‘break even’!  If the percocet have 10 mg of oxycodone in them (some have as low as 5 mg), it will take about 20 percocet per day just to prevent withdrawal! (60 mg oxycodone or 6 tabs every 6-8 hours= 18 or 20 tabs per day).  When I am taking over for post-op pain management in a person on Suboxone, I usually start at about 30 mg of oxycodone every 4-6 hours.  I keep the acetominophen out of it i.e. I don’t use percocet because you end up taking enough to harm the liver when you are taking that many percocet.  I will treat the pain with extra opiates for as long as the surgeon would generally use narcotics– that is the only way that I treat people as if they are ‘normal’.  I know that the person will need higher doses, but I don’t see a reason why the patient would need an opiate for a longer period of time.  Sometimes the patient has a hard time giving up the opiate– there is that quick rekindling of the long-lost love affair… but I say ‘tough- get over it’ and get the person back on Suboxone!
Don’t forget– to go back on Suboxone you will need to have time between the last dose of opiate agonist and taking the Suboxone.  I like 24 hours– although you may get away with less time.
Two final comments.  First, consider decreasing your daily dose of Suboxone.  If taken correctly, the opiate effects of Suboxone hit the ceiling at about 4 mg per day– so even 16 mg is overkill.  We don’t know of any significant harmful effects of chronic buprenorphine treatment, but in general, doses of any medication should be kept as low as possible.  Plus it would be cheaper for you or for your insurer!
The final comment is that even recovering opiate addicts will occasionally need pain medications.  You mentioned that you ‘don’t take pain pills’– there are times when you will simply have to take them.  People who attend 12-step meetings take them as well, while attempting to minimize their use as much as possible.  Use of pain pills that are appropriately prescribed during an honest encounter with a doctor is not considered a break in sobriety, so you don’t have to start counting clean time from scratch again!  Many people find it helpful to put a trusted person in charge of the pain medications– someone with the guts to say ‘no’ to you after the opiates have done their thing to your mind, and you are begging for more, convinced that your pain is the ‘worst pain in the whole wide world’!  Picking the person to manage your meds is similar to an AA picking a sponsor;  there is a desire to pick someone who is a pushover, but you know down deep that you are safer with someone who is a bit tough.
Michael, I wish you the best with your surgery.  I hope you are able to at least nibble on the Turkey on Thursday.
SD

Anesthesia and Suboxone, revisited…

Important enough to move to the front page:

HELP!!!!! I’m so confused. I am having surgery on Friday and have been told to stop suboxone(8mg twice a day) 24hrs prior. I’ve taken it for a little over 2 years and it has really changed my life-for the good. Now I’m scared after reading everything. I do not want it to interfere with anesthesia. Post op I had planned to go back on suboxone. The surgeon is implanting a pump that delivers xylocaine directly to the site of the surgery so I feel certain that will be a tremendous help I just don’t want to “wake up”while under general anesthesia(I’ve heard horror stories about that happening).
Someone please reply ASAP now I can’t sleep!
Thanks so much for reading this
Carrie

Reply:

Carrie, don’t worry. I am a Board Certified Anesthesiologist (I took the Boards back when they lasted for life! good for me!). It would take an idiot anesthesiologist for Suboxone to interfere with the anesthetic! Suboxone (buprenorphine) blocks only the narcotic–nothing else. During surgery there are different ways to give an anesthetic, but the ‘amnesia’ does NOT rely on opiates. In fact, it is possible to provide deep anesthesia with no opiates at all, using only the ‘inhaled’ anesthetics (that does NOT mean that YOU inhale them while awake– you are put ‘out’ using propofol, which is NOT blocked by Suboxone, and then a gas is given through the endotracheal tube or mask after you are unconscious). You can also do an anesthetic using a propofol infusion– again, not blocked in any way by Suboxone. It is possible to do a ‘narcotic-based anesthetic’, but in that case the amnesia usually comes from a low amount of gas, or a benzo, or some propofol– none of which are blocked by Suboxone. Let the anesthesiologist know you are on buprenorphine, and if he looks confused tell him it is ‘a partial agonist at the mu receptor’ and he will undertand! If he acts like you are causing him a tough day, he is only being a jerk– because Suboxone is NOT a problem.


The time it IS an issue is post-op, because that is when you need a narcotic– for pain control. Here is what I usually recommend for patients who have surgery: if you are on 16 mg of Suboxone per day, try to stop it two or three days before the surgery– that way there will be less block in the recovery room when they give you narcotic for pain. If you are on a lower daily dose– like 4-8 mg– stop the day before the surgery. In both cases you will still be partially blocked, but if they give enough narcotic you will be fine.

Don’t take Suboxone the morning of surgery. There is no need for it– the withdrawal takes 2-3 days to come on, and you are better off without the extra blockade. If you are having trouble with pain after the surgery, they should put you in the ICU, and prescribe however much narcotic it takes. The reason for the ICU is because many nurses just won’t be comfortable giving large doses of narcotic on the regular unit.

Again, Suboxone will NOT cause a person to ‘wake up’ during anesthesia– if that happens it is not from the Suboxone, it is from something else entirely. If it happens call me so I can help you get a big malpractice judgment! And afterward, tell the nurses to call your Suboxone prescriber if necessary to make sure they give you enough pain medication– I often have to get involved to comfort everyone and hold their hands so they feel safe giving the large doses that are sometimes required.

You’ll be OK.

SD

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.

Anesthesia

A comment from an anesthesiologist:
As a practicing anesthesiologist I can only reiterate that communicating with your doctors is key. I have yet to have a patient on Suboxone or their primary doctor contact me prior to surgery. I have had to cancel cases because nothing was done with the Suboxone dose prior to surgery. This is a simple fix as long as you communicate with your anesthesiologist ahead of time. I think a lot of this has to do with a lack of knowledge in the primary care arena about Suboxone.  Eric Swetland MD
Response:
Thanks Dr. Swetland for your comment.  As a former anesthesiologist I try to get patients to plan ahead and foster communication with me, the surgeon or OB, the anesthesiologist… but it still is often left for the morning of surgery.  One of my patients had a C-section a couple months ago– she told her OB to call me and I called once and left a message, but he did not call until the morning of her stat c-section, after the case was done and she was writhing in pain in the recovery room as her SPINAL wore off.  He asked what he should do, and I said ‘an epidural would have been nice….’.  I ended up recommending that they put her in the ICU and give her mega-doses of narcotics, and that is what they did.  She was fine, but an epidural would have allowed greater comfort and less expense.


Another patient had a vaginal delivery of a healthy baby;  the hospital, though, was not ‘comfortable’ with Suboxone and so a neonatologist was involved.  The patient begged him to call me–  I did not know at the time that this was going on– but he told her that ‘he knew what he was doing without calling some other doctor’ (oh, the ego!).  Against her wishes he put her baby on a morphine infusion to treat withdrawal;  the nurses were curt and rude, a couple making statements to assure she felt guilty about her baby’s ‘withdrawal’.  The nurses gave a number of conflicting statements about her wish to breastfeed her baby while taking Suboxone.  Afterward she told me that her baby looked like all the other babies before the morphine and after it was finally stopped– didn’t cry more, sleep less, etc… and I shared articles with her about the fact that newborns of Suboxone-using moms show minimal if any signs of withdrawal, and that breastfeeding is fine and results in no significant buprenorphine exposure for the infant.
I had a 67-y-o patient sent home from the ER after going in with a temp of 102 degrees F and sharp pains in the side of his chest– the doc told him ‘it was probably from the Suboxone’!!  I told him to go back, and I called the ER and told them it was NOT the Suboxone– they did x-rays this time and diagnosed his pneumonia!
Doctors have a bad habit of blaming symptoms on things they don’t know much about;  patients have their own problems by keeping their use of Suboxone to themselves, too embarassed to let their doctors know about their use.  I encourage everyone to communicate– this is a new drug and new paradigm, and it is important that everyone knows what they are dealing with.  OK… so much for the soapbox…
SD
Suboxone Talk Zone

Suboxone and Anesthesia; Suboxone vs. 'Recovery'

Yes, I have changed blog platforms again… hopefully for the last time! I spent the past few days learning to use the self-hosted WordPress platform. After reading the instructions about uploading the program using FTP (no small task for non-techies like me) I went to my GoDaddy hosting account and found that by clicking a couple buttons it automatically installed for me. Since then I have discovered the different WordPress templates available, the widgets, the plug-ins… cool stuff!

But back to Suboxone. One of the questions on today’s keywords was ‘Suboxone vs. Recovery’– I won’t go into that at length now but will direct interested readers to my article at Subox.info, where I give some thought to the different things that happen to personality when an addict takes Suboxone vs when an addict goes through traditional step-based treatment. The article is on one of the last pages of that web site.
Another keyword question was ‘Suboxone and Anesthesia’.
As you may know I worked as an anesthesiologist for about ten years before my career was skewered by my opiate addiction.  I still miss the job, but it probably wasn’t good for me… I joke that my arms were getting sore from pushing around that wheelbarrow full of money!  It certainly paid very well, but more than that I loved the feeling of power and control that comes with supporting a patient during surgery, or from totally relieving the pain of a woman in labor.  Anesthesiologists are always heroes in the hospital.  Some patients don’t know just how important the anesthesiologist is, but the nurses and surgeons certainly do.  I felt like a cowboy, as I raced in from home to secure the airway of a 13-y-o boy who had hung himself and whose neck anatomy was swollen and distorted… or as I ran down the hall to the operating room just ahead of the stretcher carrying a woman whose uterus had ruptured as she labored with her tenth kid.  I still vividly remember standing in the middle of the road at about two AM, after we saved the mom and baveby in that case.  It was snowing, and the city was asleep and very quiet, and as I looked at the dark windows of the house down the street I thought that I was the luckiest man in the world to have such a job.  A few years later the job was gone, and my feelings of power were challenged every day as I came to terms with all of the changes in my life– I was doing physical exams for a fraction of my old salary, the weekly dinner parties came to a halt (in seven years I haven’t been invited to a single one of the houses that I used to go to on a monthly basis), two close friends were dead (one a surgeon who committed suicide and the other Commander Shanower killed at the Pentagon on 9/11), our vacation cottage that the family loved was sold to pay the bills…
I didn’t intend to go down this path.  These thoughts used to be very painful for me, but now I can reflect and almost smile.  I see people in my practice who are facing changes in their lives, and it is nice to know what the situation feels like so that I can understand them.  I can also say with complete certainty that one cannot predict what the future holds, particularly when one’s view is colored by depression or other psychiatric symptoms.  I can also say that if an addict stays clean and works a recovery program, good things will ALWAYS happen.
Anyone interested in my personal story by the way can watch for a book that I am writing called ‘Terminal Uniqueness’.  I am trying to decide if I should post it on Twitter as I go or just wait until I am done.
Suboxone does not interfere with MOST anesthetics.  An anesthesiologist has a number of choices of general anesthetics (regional anesthetics using local anesthetics injected into areas to make things numb are not affected by Suboxone either).  A couple examples– one can do a ‘gas-based’ anesthetic where inhaled agents cause amnesia and anesthesia, or one can do a ‘balanced anesthetic’ using combinations of opiates and other IV medications, perhaps with smaller amounts of a gaseous agent as well.  Suboxone WILL block the opiate portion of this anesthetic, but there are plenty of other agents to use to replace the opiates.
The main problem comes after the surgery in the recovery room, when Suboxone prevents morphine, demerol, and other medication from controlling the surgical pain.  One of my patients had an emergency C-Section shortly after dosing with Suboxone and it was difficult to get her pain under control.  Eventually she was transferred to the ICU for close monitoring as they gave her huge doses of morphine– which eventually controlled her pain.  Some surgeries will be of a nature where injections of local anesthetic can provide considerable pain relief for up to twelve hours.  This is a particularly good option for procedures on the extremities.  Sometimes an epidural can help a great deal with pain control after abdominal procedures, or even chest procedures.  In cases where opiates need to be used, the dose will usually need to be surprisingly high, at levels where nobody will be comfortable unless the patient is continually monitored for respiratory function in a step-up unit like the ICU.

I have helped six or seven Suboxone patients through the surgical process and for the most part they have done well.  Stopping Suboxone for three days prior to surgery will make pain control much easier after the surgery.  Even if sufficient time has elapsed to get rid of the Subxone, though, the person will still have a much higher tolerance than patients not on Suboxone, so I strongly recommend discussion the fact that you are on Suboxone with your surgeon and your anesthesiologist.  If you don’t, they won’t know what is going on, and won’t be able to take the proper steps to help you.
SD
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Emergency Pain Relief While On Suboxone

I took a look at my blog stats today, and one of the interesting things to review is the collection of keywords that people have used on their way to this site.  Some of the keywords consist of questions, and  I will try to answer the questions as time allows.  The following question appears several times on the list of keywords:
If on small dose of suboxone and need emergency pain relief is it dangerous?
The fast answer is no– it is not dangerous.  There is a common misconception among people using Suboxone that I hate to correct, as maybe it keeps people clean.  But on the other hand there will be times when Suboxone patients need pain relief– they are not immune from car accidents, skiing accidents, work injuries, etc– and they need to know the facts about the medication they are taking.
The confusion probably occurs because Suboxone will make a person sick– sometimes very sick– if it is taken while a person is still ‘high’ on opiate agonists (or on opiate agonists and not yet withdrawing from them).  Agonists, remember, are the drugs that activate a receptor;  opiate agonists include morphine, demerol, oxycodone, hydrocodone, etc.  At the molecular level buprenorphine, the active drug in Suboxone, binds tightly to the opiate receptor, blocking the area that agonists would otherwise bind to.  (actually it is a bit more complicated– you get into probability theory when you get down to what actually happens.  The molecule of buprenorphine ‘associates with’ and ‘dissociates from’ the receptor so rapidly that the binding can be characterized by the ‘probability’ that the receptor is bound vs not bound at any moment).  As the buprenorphine alternates between bound and unbound to the receptor, it is competing with any other opiate agonists, and winning the battle, as buprenorphine is a very good ‘fit’ at the receptor.  If a person is tolerant to opiates, he/she requires agonist binding at the receptor in order to maintain the normal neuron firing patttern and avoid withdrawal.  If buprenorphine is added at that point, it will out-compete the opiate agonist and ‘displace’ it, essentially making it less likely that the receptor will be occupied by the agonist at any moment in time.  This causes less activation of the receptor, the neuron stops firing, and a series of brain events occur that result in withdrawal.
The question is concerned with a different sequence of events;  a person is taking suboxone (which is therefore bound to the receptors) and suddenly needs pain relief, and takes an opiate agonist.  In a person not on Suboxone, the goal is to over-activate the receptor and make the neuron fire more than usual, so that it sends messages down the spinal cord that reduce the ability of pain signals to get through.  But if the receptor is blocked by Suboxone, the agonist is not going to work well.  In fact, if the buprenorphine dose is high enough, the agonist won’t have any effect at all… unless it is given in very high levels.  Remember that the drugs compete at the receptor, and buprenorphine is better at competing than most agonists;  if you give enough of the agonist, it will eventually overcome the block by buprenorphine.
So if a person taking Suboxone needs pain relief (or wants to get high), normal doses of opiate agonists will not have any effect.  They won’t make the person sick either.  I recommend that patients on Suboxone carry a card in their wallet that tells EMTs that they are on an opiate blocker, in case they are injured and are unable to talk.  That way, if the person is writhing in pain in the ER as a chest tube is being inserted, the docs will hopefully give much higher doses of morphine than usual to relieve the pain.
There are two reasons to limit the dose of Suboxone to the lower range in my opinion– one is to save money, and the other is so that if an emergency occurs, it is not impossible to attain pain relief.  I tend not to restrict the dose, by the way–  I find that a dose of 16 mg works best at eliminating cravings and provides the highest margin of safety from relapse.  But a person who has a higher than average chance of needing emergency surgery may want to consider taking a lower dose, so that the block is easier to overcome during emergencies.
I have had a few patients need emergency surgery while on Suboxone.  Most did OK–  I had one poor woman though who took her morning Suboxone and then needed an emergency C-Section.  I was called by the OB doc after the surgery, when the patient was in pain in the recovery room and the spinal was wearing off.  My first thought was that if they had called before the surgery, I could have told them to place an epidural– they could then run in a dilute mixture of local anesthetic and totally relieved her pain.  But they did a spinal, so that was out (it is hard to go back and do an epidural after a spinal– positioning the patient, etc, but also, the hole in the dura mater from the spinal can make an epidural more erratic and potentially dangerous).  Other options included IV toradol, an aspirin-type medication, as long as bleeding wasn’t a problem. This patient still had severe pain though, so using the principle of competition at the receptor, I recommended that they move the decimal in their dosing of morphine and just give what it takes.  She went to the ICU for monitoring and they gave her BIG doses of morphine– 20, 30, 50 mg at a time.  Everyone was nervous, but it worked.  (the concern is respiratory depression–  that is why she went to the ICU, as the floor nurses were appropriately too nervous to give those kind of doses without being able to watch respiratory rate closely).  The only problem with such high doses of morphine is that IV morphine can cause release of histamine in the bloodstream– the nasty chemical that makes you sneeze, itch, and swell during allergies.  After a couple doses the available histamine is ‘used up’ and not a problem, but the first dose or two should be smaller, and then gradually increase, in order to prevent a massive histamine reaction.  Some benadryl is helpful as well.
A couple final comments:  Do NOT engage in trying to ‘out-compete’ your own receptors using opiate agonists, while taking Suboxone.  Doing so is very dangerous, as you can go from a non-competing dose to an out-competing dose without realizing it until too late– and the result would be a fatal overdose from respiratory arrest.  Respiratory monitoring is necessary whenever this type of thing is going on!!!!  The other thing is that while the principle of competition is straightforward, do not be surprised if you doctor refuses to go along.  Most doctors are freaked out by giving such high doses of narcotics.  I was an anesthesiologist for 10 years, so for me it is not a big deal… but most surgeons, unfortunately, are more comfortable with a moaning patient than with writing for real high doses of morphine.  ALWAYS plan ahead for surgery if at all possible– talk to the anesthesiologist, the surgeon, and anyone else who will be involved in your care.  Have a plan in place to deal with the pain.
If the surgery is planned I recommend stopping the Suboxone at least 3 days before the surgery so that it gets to a low level in your system by the day of surgery.  It takes a LONG time to clear buprenorphine!  And let your surgeon know that you are taking an opiate blocker, and that your tolerance is artificially much higher than normal.  Again, I hate to generalize in a negative way but some doctors, when told of a high tolerance and need for higher doses, respond by being more stingy with the dosing!!  (you know–  BAD addict! BAD!  BAD!!).  The dose of every medication has limits, but people addicted to opioid have the same right to reasonable analgesia as other patients.