Post-Operative Pain in Suboxone Patients

Originally posted 12/19/2012

I’ve written about this topic a number of times, but I continue to receive emails from people on buprenorphine who describe inadequate pain control following surgery.  I have prepared a document for my own patients to provide to surgeons, dentists, and ER staff to be used in the case of injury or surgery.  A copy of that document can be found below, or can be downloaded here.

As with any of my comments, the information below must be used in consultation with your OWN buprenorphine-certified physician.  Feel free to use my comments as a starting point for discussions about upcoming surgery or dental work.   But do NOT use the information to treat yourself, for example using medication or substances that were not prescribed for you.  Taking opioid agonists while treated with buprenorphine requires careful consideration, as the risks of opioid use include respiratory and cardiac arrest (i.e. death).

Re:  Surgery in Patients on Buprenorphine

Buprenorphine is a partial opioid agonist that is used for several indications.  In low doses—less than 1 mg—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.

Xanax Worsens Anxiety and Panic

First posted 12/13/2012

Anxiety is one of the most common presenting complaints for people who come to my psychiatric practice. By the time people with anxiety visit a psychiatrist, they have usually discussed their symptoms with friends and family members, and some have been to their family care physician. And as a result of these initial ‘consultations’, they often have been recommended or prescribed valium-type medications like Xanax or Klonopin— a class of chemicals known as ‘benzodiazepines.’

There have also been several highly publicized deaths from combining pain pills with benzodiazepines. The medications are commonly prescribed, and there are a number of misconceptions among laypeople about their proper use. I’ve written about this class of medications in the past, but given the frequency that they are prescribed and mis-prescribed, the topic deserves another visit.

Most experienced doctors have learned to cringe every time a patient says the word “anxiety,” knowing that in all likelihood they are in a lose/lose position. Why lose/lose? Because the experienced doctor knows that the options are to do the right thing and disappoint their patient, or do the wrong thing and struggle with the consequences of their actions for months or years.

Marijuana Laws: Progressive Change or Society’s Downfall?

Originally posted 12/8/2012

I’ve been hearing more calls these days to change US marijuana laws (note- Colorado and Washington legalized recreational use of marijuana shortly after this article was originally posted).  Legalizing marijuana has been a cause for some citizens for decades, and efforts to change marijuana laws have waxed and waned since I was a teenager in the 1970’s.  Some people believe that this time around, attitudes are truly changing.  A recentQuinnipiac University poll  showed that as of November 2012, a majority of US voters favor legalization of the drug for recreational use.

The current status of marijuana laws are confusing, to say the least. Marijuana is regulated at multiple jurisdictional levels, so a person in any one location is subject to state, federal, and sometimes local laws.  These laws are often at odds with each other, so the legality of marijuana depends largely on the employer of the agent or officer making the arrest.

There are also multiple forms of legality. In November, Colorado and Washington State legalized possessing up to one ounce of marijuana.  Another dozen-or-so states decriminalized marijuana over the past 20 years, so that possession of the drug is punishable by citation, not prison time.  Another 20 or so states have laws allowing for the medical use of marijuana, including in some cases provisions to grow marijuana for personal use or for a small number of patients.

Questions and Answers about Opioid Dependence and Buprenorphine