Having Surgery: When to Stop Suboxone?

A question about Suboxone and Surgery:

Hi-this is in reply to your message back to me. I am the girl who is soon to have surgery. You said that 3 days would be good to be off the suboxone, but you said the worst withdrawal takes about 3 days to hit, so it’s a bit of a compromise. But, won’t the withdrawal be halted once the pain medication gets into my body? Are you just saying that I will have to deal with some detox discomfort during the 3 day period? I, unlike many people, know quite a bit about suboxone (it is so surprising how many people are clueless), but the one thing I am not clear on is how long it would take to “feel” opiates after stopping suboxone (thank God I am ignorrant in this area!). On one of your blogs you said that opiates would work as short as a day afterwards, but that you would have to have quite a bit to get past the buprenorphine. I just dont think I can go off of them for 3 days prior to surgery. I am on 16 mg 2x a day.

My Response:

You are on a pretty large dose of Suboxone.  Everything is relative, but about 4 months ago the manufacturer of Suboxone sent a notice to doctors and pharmacists saying that because of the ceiling effect of buprenorphine, and because of the diversion of the drug, the maximum dose should be no more than 16 mg per day. The notice went on to state that a rare patient may require doses of up to 24 mg for a very short period of time, but that higher doses were never indicated.

In my local area, one clinic uses a max dose of 4 mg per day, a dose that I consider to be too low, but in my own practice I almost never use doses about 16 mg per day.  Overall, 30% of my patients take 8-12 mg per day, 60% take 12-16 mg per day, 3% take 16-24 mg per day, and the remaining 7% (7 patients) take less than 8 mg per day.

If the dose is taken correctly so that maximum uptake occurs, there is no subjective difference between 8 and 16 mg per day.  I have taken a number of people down in dose from 16 to 8 mg, and there is never any significant withdrawal;  there is, though, the ‘imaginary withdrawal’ that happens so much with early use of Suboxone. What is the difference?  Real withdrawal lasts until the person takes another dose;  the ‘imaginary withdrawal’ comes in waves, and then disappears as soon as the person is distracted a little bit.

Grrl, I strongly recommend that you get your dose down to 8 mg or so per day before surgery.  The blockade of the receptor is competitive;  it will be almost impossible to get enough agonist to overcome the blockade of 32 mg of daily buprenorphine.  Yes, 1000 mg of oxycodone might do it, but you will never get anyone to give you that amount in a hospital.  Even the less-ridiculous doses are hard to get, as every person in the chain gets in the way.  The surgeon doesn’t want to write for such high doses, as he doesn’t want to take the time to explain why he is doing so to all of the people who will be calling him.  The unit secretary doesn’t want to transcribe the order until she calls the surgeon to say, ‘are you sure you want THIS MUCH?’  Then the nurse won’t want to  give such a large dose, especially without monitoring– meaning that he/she will suddenly be pushing to get you transferred to the ICU.  The pharmacist may nix the whole thing, and simply say that ‘he isn’t going to risk his license by releasing so much narcotic’. Meanwhile, you will be writhing in pain as the hours go by.

The lower you can get your daily dose, the less buprenorphine you will have in your body to block the post-op medications.  Yes if you stop entirely three days in advance, you won’t have significant withdrawal for a few days… and by that time you will be getting the post-op pain meds.

A couple things… an anesthesiologist wrote and said that in his experience the lipid-soluble and high-potency opiates seem to ‘compete’ more effectively at he opiate receptor, and that they therefore are better choices for post-op pain.  Remember, though, that you will have TWO problems with getting pain relief;  the first is the competetive block of your opiate receptors, and the second is the high tolerance you will be left with, even after the buprenorphine is gone.

Your last question about how long it would take to ‘feel’ agonists after Suboxone… it would depend, of course, on the dose of agonist, the type of agonist, and the dose of Suboxone.  The bottom line is that it always takes much longer than people expect.  I have had a couple people who needed to go back to agonists for pain, and they said something similar to each other– that even after weeks off the suboxone, they could never get the same old ‘euphoric’ feeling again.  I don’t know if that is from some small lingering amount of Suboxone, or from the remaining elevated tolerance persisting for a long time after stopping the drug… But whatever it is, it will be difficult to get relief from opiate agonists for some time after stopping Suboxone.  And the people who stop Suboxone for a day, hoping to catch a buzz from a couple 40’s, will be disappointed!

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3 thoughts on “Having Surgery: When to Stop Suboxone?”

  1. I’m glad I landed on this article because I’m 4 days from having thyroid surgery. My surgery will be at the University of Pennsylvania and anyone on the east coast knows that it’s one of the most reputable hospitals in the tri-state area. Amazingly enough, my surgeon and the anesthesiologist weren’t (and aren’t) very familiar with suboxone.
    I went to suboxone.com and called their customer service number. The super kind woman on the phone directed me to http://www.naabt.org (National Alliance of Advocates for Buprenorphine Treatment).
    She answered my question pertaining to how long I should stop taking suboxone prior to surgery. I’m on 2mg once or twice a day, so unlike the girl in the article, I’m not taking a large amount. The answer to how many days/hours prior they recommend you stop taking suboxone before surgery is answered here: http://www.naabt.org/faqs.cfm

    Scroll a little more than halfway down to “What if I need pain medication for surgery, or acute pain?”

    There you will see in the paragraph it says:
    “You will still be able to be treated for pain with elective dental or surgical procedures. Your doctors should speak with each other about the plan. They will likely stop your Buprenorphine medication, at least 36 hours before the procedure, and then when you are ready to go back on Buprenorphine you will need to be re-induced, which means stopping your pain medicine, experiencing mild withdrawal (for a very short time) and restarting your Buprenorphine.”

  2. I have had surgery due to several fractures in my pelvis and a ruptured colon and the doctor knew I was on suboxone but did the surgery because I was loosing blood fast. It was hard to control the pain the first 3 days but then I felt the pain meds they had to give me hydromorphone and alot of it. In July I had to have emergency surgery to remove my gallbladder and I had mabye 48 hours without any suboxone and my pain level was controlled with a coctail of morphine and hydromorphone because they had to do open surgery and I am still having severe pain went to the ER last night because I have not slept more than 5 or 6 hours in a week and a half. The ER doctor told me he couldnt give me a script not even non narcotic. I asked for Ultram and the doctor said it was a narcotic. He lied strait to my face. I am a RN and I know for a fact Ulram isnt a narcotic it is controlled but I was so pissed I am tired of being called a junkie when I dont even ask for narcotics I dont go to the ER unless I have to cause I hate they way the descriminate. I am in so much pain and so tired I really think I am loosing my mind. I crie sometimes for no reason and sometimes because the pain and sleep deprevation is to much to take. I am no doctor just sharing my past experiences with surgery. Good luck I would think about 4 to 5 days if possible before surgery but not an expert. I am new I am glad I found this site hope I can help anyway I can. Keep your head up and Dont give up life is to short. Peace to the Beast

  3. I am involved in 12 step NA meetings, and at one time had 8 yrs. clean from all drugs. Then I had surgery and relapsed with pain meds, and I never used opiates in my using days…go figure, addiction is cunning, baffling and powerful. I used opiates other than heroin for about 3 yrs. and then found Suboxone and got involved in my recovery program again. I have been on 8 mg. of Suboxone for 3 months and I am having hand surgery so I was looking for answers about taking my medication or discontinuing it temporarily. My prescribing doctor told me it is also used for pain relief and to just continue taking it, but I did not feel that his answer was detailed or informative so I researched it. This is what I found in the latest research on http://www.naabt.org, and I hope it helps others. Let me know your opinion of this.

    Recommendations for Patients Receiving Maintenance Buprenorphine Therapy

    Clinical experience treating acute pain in patients receiving maintenance therapy with buprenorphine is limited. Pain treatment with opioids is complicated by the high affinity of buprenorphine for the  receptor. This
    high affinity risks displacement of, or competition with full opioid agonist analgesics when buprenorphine is administered concurrently or sequentially. There are several possible approaches for treating acute pain that requires opioid analgesia in the patient receiving buprenorphine
    therapy (Table 2). With such limited clinical experience, the following treatment approaches are based on available literature, pharmacologic principles, and published recommendations. The most effective approach will be elucidated with increased clinical experience. In all cases, because of highly variable rates of buprenorphine dissociation
    from the  receptor, naloxone should be available and level of consciousness and respiration should be frequently monitored.

    Treatment options are as follows.
    1. Continue buprenorphine maintenance therapy and titrate a short-acting opioid analgesic to effect (90, 98). Because higher doses of full opioid agonist analgesics may be required to compete with buprenorphine at the  receptor, caution should be taken if the patient’s buprenorphine
    therapy is abruptly discontinued. Increased sensitivity to the full agonist with respect to sedation and respiratory depression could occur.
    2. Divide the daily dose of buprenorphine and administer it every 6 to 8 hours to take advantage of its analgesic properties. For example, for buprenorphine at 32 mg daily, the split dose would be 8 mg every 6 hours. The available literature suggests that acute pain can be effectively managed with as little as 0.4 mg of buprenorphine given sublingually
    every 8 hours in patients who are opioid naive (47, 99, 100). However, these low doses may not provide effective analgesia in patients with opioid tolerance who are receiving OAT. Therefore, in addition to divided dosing of buprenorphine, effective analgesia may require the use of
    additional opioid agonist analgesics (for example, morphine).
    3. Discontinue buprenorphine therapy and treat the patient with full scheduled opioid agonist analgesics by titrating to effect to avoid withdrawal and then to achieve analgesia (for example, sustained-release and immediaterelease morphine) (90, 98, 101). With resolution of the
    acute pain, discontinue the full opioid agonist analgesic and resume maintenance therapy with buprenorphine, using an induction protocol (98, 102).
    4. If the patient is hospitalized with acute pain, his or her baseline opioid requirement can be managed and opioid withdrawal can be prevented by converting buprenorphine to methadone at 30 to 40 mg/d. At this dose, methadone will prevent acute withdrawal in most patients (97) and, unlike buprenorphine, binds less tightly to the  receptor. Thus, responses to additional opioid agonist analgesics will be as expected (that is, increasing dose will provide increasing analgesia). If opioid withdrawal persists, subsequent daily methadone doses can be increased in 5- to
    10-mg increments (103). This method allows titration of the opioid analgesic for pain control in the absence of opioid withdrawal. When the acute pain resolves, discontinue the therapy with the full opioid agonist analgesic and methadone and resume maintenance therapy with buprenorphine, using an induction protocol (98, 102). If the patient is discharged while full opioid agonist analgesics are still required, then discontinue methadone therapy and treat the patient as stated in the third buprenorphine approach. If buprenorphine therapy needs to be restarted (buprenorphine induction) after acute pain management (that is, the third and fourth approaches), it is important to keep in mind that buprenorphine can precipitate opioid with-drawal. Thus, a patient receiving a full opioid agonist regularly should be in mild opioid withdrawal before restarting
    buprenorphine therapy (98, 102).Acute PainManagement for Patients Receiving OAT Perspective http://www.annals.org 17 January 2006 Annals of Internal Medicine Volume 144 • Number 2 131