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?

Fentany for pain on Suboxone?
On Suboxone and having surgery

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.


kara · November 26, 2008 at 1:19 pm

That answer kind of worries me. I am having surgery next week. I have been on Sub 8mg for nearly 2 years now (gosh that seems like a long time, but beside the point for right now). Anyway, I went from 8mg to 4mg a couple of weeks ago. For the last 3 days I have been on 2mg. I took the last 2mg pill that I plan on taking until the surgery (next Thursday – so a full week). It sounds like the sub will be completely out of my system by then, but I will still have a high tolerance? Will I really need that much pain medication afterward to control the pain? 20 pills per day of 10mg oxycodone seems pretty scary to me, but I am terrified of being in pain too. I told the nurse that because of the sub, my tolerance would be high and that vicodin wasn’t going to do anything for me. She wrote that down and said the doc would prescribe percocet, but she didn’t say what the dose would be. She also said that perocet was the strongest thing they could prescribe. What should I do? I have an appt with my sub doctor on Monday, but I don’t know how willing he will be to give me really strong meds. I’m not even sure how to ask him. What do I say to him and how much pain med do you think I really need? Surely not morphine or anything, right? As an aside, I intend to go right back on the sub after the pain is gone, but you said I should wait 24 hours?
Thanks for any info you can give me.

jimwalsh · November 28, 2008 at 11:08 am

I am a physician in Seattle. In two c-section cases we have found that high affinity opiates (fentanyl or hydromorphone) delivered by PCA can provide adequate anesthesia even while sublingual buprenorphine is continued.

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