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.

9 thoughts on “Acute pain e.g. surgery while taking Suboxone”

  1. 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

  2. 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

  3. I just wanted to give you a big thank you for responding so fast. I tried to reach my psychiatrist-at least the nurse-to see if they could help calm my nerves but I got no return call! Not happy about that. Regardless, my surgery is scheduled for tomorrow and I’m nervous but am calmer now thanks to your response. They are implanting a pump of some sort that delivers marcaine directly to the incision and I’m supposed to not experience severe pain. I hope that works-plus I will be using lots of ice!
    Fortunately my husband and I are both RN’s(I of course no longer practice unfortunately)so we know that alternatives work when given the chance-I just hope they do this time(postop anyway)I do not want to take an opiate and just want to restart the suboxone at the regular dose, along with some anti inflammatories. The suboxone has been a real lifesaver over the last two years and I don’t want to jeopardise my progress. When I began treatment for addiction I was ultimately diagnosed with bipolar disorder-have a family history of as well and it has taken 14-16 months to finally get my mood stabilized-so needless to say I’m terrified of changes in medications now.
    I also wanted to say Thanks for this site. Last night was my first visit but I will be back-it’s nice to be able to relate to others. Many people don’t understand what goes on in our lives and attach such a stigma.
    Oh, one last thing-I clicked on a “donate”link-and made a donation-I hope that is for this site?
    Thanks again and keep me in your thoughts tomorrow
    Carrie

  4. My experience having a very infected tooth removed was fine.(and a great relief).
    I believe a local anesthetic was used, and Motrin© afterwards. (plus my usual Suboxone©) ymmv
    The dentist made no big deal, but I did tell them-they said it would be no problem and it wasn’t.
    I had been wiggling the tooth a lot before I got there, so that may have helped?
    (it was a little loose).
    It was a very large bottom, back molar.
    Thank-you to the anesthesiologist who posted the excellent info. about surgery–I’ve always been worried about that.
    I had a problem a few years ago in the ER, and they refused to give me Suboxone© or any other opiate in the hospital-but that’s another story.
    If I ever end-up there, or similar, I think I’ll tell them to talk to the anesthesiologist.

  5. Thanks for sharing your experience. Yes, there is a great deal of ignorance among medical professionals. I blame the stigma of addiction for the lack of education– I cannot think of any other area of medicine where doctors have so neglected to keep current and learn about a popular new treatment.

    On a separate issue, I have had many patients describe unusual pain experiences while taking Suboxone– in every case experiences where the person had less pain than expected. The most dramatic was a woman who had her gallbladder removed after being on Suboxone for a few months. Her surgery was ‘open’, not laparascopic, and that is usually a very painful procedure to recover from… she took nothing but Suboxone and never called me, and afterward said she did fine. I would have expected her to have significant tolerance to the Suboxone, and yet she had minimal pain. The only thing I can conclude is that her pain was affected by her expectations– that she expected the Suboxone to help, and so it did. This would be similar to the way that hypnosis modulates pain… but I would not expect such a mechanism to have such a powerful effect on pain of this magnitude.

    Feel free to share your own experiences with pain and Suboxone. I should point out that in MOST cases additional opiate agonists are required and appropriate when a person on Suboxone has surgery.

    SD

  6. This is so good to read because I am facing spinal surgery for the second time- first was in 12/07. The recovery from my surgery was horrible (now I know it’s because the fusion I had isn’t fusing and the plate that’s in there has “settled”). I’ve been on suboxone for about 9 months. Before the surgery I had almost 7 years of total sobriety, active in AA, etc. When I was honest w/ MDs about my history, I definitely got treated differently- like my pain wasn’t real and I was drug seeking. Anyway, I’ve done well on soboxone, but never really have had adequate pain relief. I’m not using anyting else except tylenol, but now I found out I have another herniated disc, a compressed spinal cord, and just a whole host of serious cervical spine issues. I’m facing more surgery but am waiting for a 2nd opinion. When I saw my NS last week I told him I was on suboxone and he didn’t even know what it was! I feel I’m hanging in this awful void and I really didn’t know any of this about how long it would take for suboxone to stop hanging onto those receptors. I’m quite anxious about my whole situation. My pain and symptoms are worsening, I don’t even know what to do- call the suboxone Dr? The NS is no help becuase they’ve handled my care poorly since the post-op visit.
    Sorry to ramble, just overwhelmed and I saw a lot here I could identify with. Any suggestions are appreciated. Thanks Amy

  7. Amy, stay in touch. I will answer when I have time; you can also tell your NS to contact me if he has any questions… although from my time as an anesthesiologist I know that no neurosurgeon is going to ask ‘some shrink’ for information! Maybe if you tell him I used to ‘pass gas’ he will take the bait…

    I would be happy to take you on as a patient, but I don’t like prescribing ‘schedule II’s’ across state lines (Suboxone is a schedule III, but oxy is a schedule II, and you will need oxycodone after your surgery for at least a few days). If you need someone for Suboxone after the oxycodone is done, feel free to check me out at http://wisconsinopiates.com or http://telemedpsychiatry.com .
    SD

  8. Thanks a lot for the answer. I do have a suboxone doc obviously, as well as a psychiatrist who specializes in addiction psych- he isn’t a sub doc but recommended I go on it after months of opiates w/o much pain relief and a HUGE tolerance. Then there is the NS who stopped me cold turkey from vics. When I suggested the possibility that I would withdraw (knowing full well I would) he said,”How long have you been on them?” I answered 7 mos. (that was vics prescribed at a max of 8/day, by then it took me 6 at a time to get any effect, so I was running up quite a bill w/ needed extras.) He said,”Oh, you’ll be fine, that’s not too long. With your past, we want you off these and I can’t continue to manage your pain.” I panicked and his PA gave me a script for 30 and told me to taper. I was pretty much left to my own devices. My shrink and counselor saw me going downhill, and wanted me to get off the vics. After some apprehension, I started sub in 4/07. I couldn’t believe the difference.
    So, I see my sub doc 1x/ mo. I was doing well w/ pain for a while. When it started to get bad again, He told me to go from the 16 mg./ day (8mg around 730, another 8 around 200) to 8mg in the a.m., 8mg around 12-100, and a half tab around 8 p.m.. This was, he said, to try to get the best benefit of the pain relieving properties of the sub. At this point, it’s not helping. I don’t know what to do. The pain is really interfering w/ my life. I’m a single mom of a 9 yo son. He worries about me because he sees me hurting and is upset because I can’t do the things I used to w/ him. I feel terrible. We go to a counselor for him too which has been great.

    After all these mos. of being told by the NS PA (who only always called back after my reprated calls) that my fusion was healing well (C5-C7), actually things have gotten worse. I obtained all my own reports of my MRI, xrays- and was blown away at the deterioration in my spine. This doc never compared my reports over time, sent me back to an extremely physically demanding job, and, again, only returned my call re: the last MRI after three weks of my repeated calls me then asking his sec. for all my records. Only then did the PA get on the phone. I told him my concerns, the things I had read on my report, my worsening symptoms. Certain things I mentioned like the fact that C4-5 was now herniated, and the screw palcement in C7 appeared to be in the disc. (The disc was taken out, so actually it was the failed fusion that it showed.) he responded,”I never saw that, which report was it on?” like it was a pulled muscle. It has continued like this.

    My biggest concern is that I’m going to face the judgement of the medical community that I’ll have to be involved with while the surgery and post-op period go on and my pain will not be adequately treated. It has happened so many times. They’re talking some pretty major surgery, and I know how absolutely awful I felt afterwards. They were giving me 4-6 mg. of morphine every 4 hrs. and I had a lot of breakthrough pain, and never full relief. Now, with this extra added issue of being on the suboxone, I’m more scared that I won’t be able to find a doc willing to help.
    I’m going to call my sub doc and see what he says, but will check out the other web sites you sent. Thanks to anyone who can idewntify and share any tips q/ me.

  9. Amy, I don’t have an answer. Your situation is horrible– and one that just doesn’t have a solution. You will need much higher doses of morphine to treat post-op pain in a patient who is opiate-tolerant, even without Suboxone! I have a patient who had a C-Section while on Suboxone, and she needed doses of 20-30 mg of morphine every few hours. I wonder if you could have a meeting with your NS before any surgery and discuss the issue… there is a link on the right ‘blogroll’ for ‘war on doctors’– through that site you will find people who work to get appropriate amounts of pain medication for patients who need it.

    As for long-term treatment of the pain, there just is not an answer. If you use opiate agonists, they will take over your thinking– as you already know. Even worse, tolerance will take away the effect of the medication. If the dose is raised, any relief will be temporary, as tolerance will take the effect away.

    I don’t like being negative– but I hate telling patients things that are not true. The goal in treating a person in your situation is to ‘distract them from the pain’ as much as possible– and if I said that to you in person you would probably hit me!

    I don’t like dosing Suboxone multiple times per day; in my experience that only ‘unconsciously’ draws the patient’s attention more toward how much it hurts, as a part of the person is always thinking, ‘do I need it yet’? Plus the half-life is very long–75 hours– making more than one dose per day totally unnecessary. Any benefit from the extra doses are truly psychological– a type of placebo effect.

    Please check out the link I mentioned– there are good people there. And feel free to post as much as you need, to ask questions of whoever may be reading. take care.

    SD