Post-Operative Pain in Suboxone Patients

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 […]

Xanax for Anxiety? Think Again!

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 […]

Is My Withdrawal Permanent?!

A question from a reader: I am trying to decide what my best course of action might be in dealing with protracted withdrawals from a number of drugs, including benzodiazepines. My history is as follows:  I was snorting Oxycontin for about 6 months and went into treatment to stop.  Before entering the rehab hospital they […]

Withdrawal from Suboxone or Buprenorphine

I received a question from a reader about withdrawal symptoms from stopping buprenorphine. My answer has relevance to opioid withdrawal in general, and to a common misconception about the duration of withdrawal symptoms. The message: Basically I quit Suboxone about 18 days ago. When I decided to quit I was taking about 8 to 12mgs per day. I […]

A Save with Suboxone?

I’d like to share a recent email exchange with a reader. The post is long, but there are several interesting aspects to the discussion. I’ve removed the conversational parts, as well as the identifying information. The initial message: I was an intravenous heroin user for three years. After treatment I was able to stay clean […]

Questions, Excuses, Krokodil

I’ve been in more of a chatty mood lately, as regular readers have likely noticed.  I find it interesting that weeks will pass when I have little or nothing to say… and at other times, I have all sorts of random thoughts to discuss.

Excuses first– I’ve been tinkering with ads for the past few days, and I apologize to those of you who tried to read a post while I was activating and deactivating Wordpress plug-ins.  After experimenting with different colors I’ve decided that basic grayscale is the best.  For those who don’t blog, ‘plug-ins’ are small, add-on programs that add a range of functions to a blog.  There are literally thousands of them out there;  some free, some for a small charge.  A couple dozen plug-ins are designed to add the code for Google Adsense to a blog, with a range of features including adding ads randomly to old posts, etc.  I’ve found that some work better than others; a couple of them really messed up the other blog functions, causing the top banner to appear at the bottom and vice versa.  I THINK I have things working OK now;  if you are having trouble, please send me an email (drj at Suboxonetalkzone dot com) and tell me the nature of the problen, and the browser and operating system you are using.  Thanks!

Another neat feature of WordPress is that you can review a number of different statistics for a blog, including the keyword that each viewer searched for before arriving at the site.  I see certain questions posted over and over;  I presume those questions are about things that come up often in the lives of people on Suboxone.  I used to do ‘questions and answers’ on a regular basis;  I’ll try to get back to those now and then, using the most popular queries as starting points.

Yesterday, several people searched for phrases related to buprenorphine and workplace drug testing.  I’ve received a number of questions by email about that same topic.  People wonder if Suboxone (buprenorphine) shows up in drug testing, and whether they should disclose that they take the medication before the test.  This is a very tough issue.  I believe that people who take Suboxone properly are NOT impaired by the medication.  There was an article from the Mayo Clinic Proceedings recently that claimed that people ARE impaired by Suboxone, and therefore certain occupations– notably physicians and nurses– should not work at those jobs, if taking Suboxone.

There were at least two things that made their conclusions… ridiculous.  First, the authors wrote that doctors’ work is so uniquely difficult, that it challenges gray matter so much more heavily than other occupations, that doctors should avoid buprenorphine treatment.  To that, I say that a recovering anesthesiologist taking Suboxone is much safer than a recovering anesthesiologist, holding fentanyl in his/her hand, not on Suboxone!  Even if you take away the risk that the non-Suboxone doctor is using, one must consider the effects of cravings on vigilance.  I’ll take the doc on Suboxone, who is placing all of his attention on ME, over the guy reciting the serenity prayer to himself and pondering the decision over what can be ‘changed’ and what can’t!  Of course, that’s just me…

I was also impressed by the ego of the writers, who think that a pediatrician or radiologist has greater need for an ‘unmedicated brain’ than a jet pilot, or a welder ten stories up, or a long-haul trucker, or a nuclear physicist. Yes– doctor jobs are ‘uniquely’ difficult!  (add sarcasm here).

The conclusions were deeply flawed in other ways.  To determine the effects of Suboxone on performance, they looked at studies that gave people opioid agonists or buprenorphine, and concluded that the effects were similar.  I mean really– people who are not on Suboxone regularly, without a tolerance to opioids, taking buprenorphine?  OF COURSE the people were messed up!  Suboxone has potent opioid effects;  there is no argument to that point.  But the unique ceiling effects of buprenorphine allow the subjective effects to go away, as tolerance is established.  That’s the whole point of Suboxone treatment!

I’m off on a tangent, right?  Back  to drug testing…  I do not think that people on Suboxone, who take it properly, are impaired in any way.  So I do not believe that people should have to disclose their treatment, and their history, to their potential employers.  But my opinions on the matter are irrelevant, unless the new/old President-elect appoints me as Attorney General… and odds are not in favor of that happening.

I can say that I’ve received 20-30 emails over the years, asking about employee drug testing.  In each case I asked the writer to follow-up and let me know what happened.  Some ended up disclosing that they were on Suboxone, and most did not.  To date, nobody has written back to say that they were denied the job over the issue.  I therefore conclude that most employers are ignoring buprenorphine, at least at this point.  That’s the best answer I have;  I can’t recommend any specific course of action.

Finally… today I came across an old post on my forum about a drug that was sweeping across Russia last year, called Krokodil.  The drug apparently is made from over-the-counter codeine tablets, in a process that creates a cheap concoction of opioids in a toxic sludge.  Users of the drug describe withdrawal more severe than opioid withdrawal, that includes seizures.  And within days of starting a habit, users slough off large sections of skin and other tissue from their arms, legs, torso– even from the face.  Not for the faint of heart— if you search the name of the drug under Google Images, you will find horrifying photographs of the damage inflicted on people addicted to the substance.

If anyone really thinks that drug addiction is a ‘choice,’ please tell me what, exactly, those tragic people were thinking.

Post-op Pain on Suboxone

I often receive emails from patients on buprenorphine (or Suboxone) who are preparing for surgery or other painful medical procedures. Ideally in such cases, the surgeon would have a discussion with the person prescribing buprenorphine, in order to coordinate the plan for treating postoperative pain. In practice such discussions don’t seem to take place, leaving patients to scramble for effective pain control after surgery– when it is too late to take the steps necessary for a smooth perioperative course.

I am familiar with an NIH article that describes pain control in people who take buprenorphine. I’ve also prepared a handbook that describes the issues that must be considered in such patients; the handbook can be found easily-enough by searching for the User’s Guide to Suboxone.

Even with those descriptions ‘out there,’ I’ll get requests for a short, ‘just-the-facts’ note that patients can give to their surgeons. I realize that unfortunately, the average surgeon will not sit down for an in-depth discussion of post-op pain control, so I have prepared a few paragraphs that lay out the issues. People on buprenorphine who are having surgery are welcome to copy the paragraphs below and give them to their surgeons, in order to facilitate discussion.

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 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.

There are two hurdles to providing effective analgesia for patients taking buprenorphine: 1. the high opioid tolerance of these individuals, and 2. The opioid-blocking actions of buprenorphine. The first can be overcome by using a sufficient dose of opioid agonist, on the order of 60 mg per day of oxycodone equivalents or more. The second can be handled by either stopping the buprenorphine a couple weeks before agonists are required—something that most patients on the medication find very difficult to do—or by reducing the dose of buprenorphine to 4-8 mg per day, starting the day before surgery and continuing post-operatively. Given the long half-life of buprenorphine, it is difficult to know exactly how much remains in the body after ‘holding’ the medication. That fact, along with the difficulty patients have in stopping the medication, leads some physicians to use the latter approach- i.e. to continue 4 mg of buprenorphine per day throughout the postoperative period. People taking 4-8 mg of daily buprenorphine report that opioid agonists relieve pain if taken in sufficient dosage, but the subjective experience is different, in that there is no feeling of euphoria.

Quick Notes:

Patients taking maintenance doses of buprenorphine do NOT receive surgical analgesia from the medication, as they are completely tolerant to the mu-opioid effects of buprenorphine after the first week or so on the medication.

Discontinuation of high dose buprenorphine or Suboxone treatment results in significant opioid withdrawal symptoms within 24-48 hours.

Normal amounts of opioid pain medication are NOT sufficient for treating pain in people on buprenorphine maintenance.

Opioid agonists will NOT cause withdrawal in people on buprenorphine. Initiating buprenorphine WILL cause withdrawal in someone who is tolerant to opioid agonists, unless the person is in physical withdrawal before initiating buprenorphine.

Non-narcotic pain relievers CAN and should be used for pain whenever possible in people on buprenorphine to reduce need for opioids.

Tough Choice

I have been struggling with part II, primarily because there are no easy answers to the situation. I realize that I could easily criticize whichever path a doctor suggests for our imaginary patient.

As an aside, I believe that a major reason for the lack of sufficient prescribers of buprenorphine in some parts of the country is the ‘damned if I do, or damned if I don’t’ scenario. All docs are aware of the current epidemic of opioid overdose deaths, and I think most doctors assume that tighter regulations on opioids are appropriate, and are just around the corner. Some addiction physicians and some pain physicians, particularly those who prescribe opioids, fear being grouped by the media, DEA, or a licensing board as part of the problem, rather than as part of the solution. I recently read of a doctor charged with manslaughter for being one of several prescribers for a person who died from opioid overdose. He prescribed meperidine—and outdated and toxic medication—which likely contributed to the charges… but the story creates a chilling atmosphere, regardless. Suboxone and buprenorphine are much safer medications, but when the target population consists of people with addictions to opioids, there will always be some people who use the medication inappropriately— some with disastrous results.

For those late to the party, we are discussing the best treatment approach for someone who cannot control using opioids, but who for now, at least, has a low opioid tolerance. Starting buprenorphine in such a patient will cause opioid side effects, as described in an email that I received from a woman who was addicted to hydrocodone for four years, who stopped taking hydrocodone for 7 days before induction with buprenorphine.

She wrote:

This Suboxone is making me feel like crap. He has me on 8mg/2mg sublingual 2/day. It’s awful…

She had been taking 20-30 mg of hydrocodone up to 5 times per day, stopping them a week before induction. She continued:

Have had a headache in the base of my skull since starting Sub 4 days ago, nausea, vomiting, sweating a lot, face feels like it’s on fire, can’t taste anything, throat hurts, can’t sleep because my face & eyes itch so bad that I’ve rubbed them raw.

These are classic side-effects of over-narcotization from buprenorphine. A person in this position typically feels better holding the buprenorphine, and when the nausea is eventually gone, taking a greatly reduced dose of the medication. The problem is that if the dose is too low, there is no advantage to buprenorphine over other opioids. The whole point of taking Suboxone is to stay on a blood level HIGHER than the ceiling effect, as that essentially tricks the brain, since the opioid effect stays constant even as the blood level falls.

In a few days, the writer’s tolerance will increase to a level where she can take an entire dose of Suboxone without nausea. And by that time, the medication will greatly reduce the desire to take opioids.

Will she be better off on buprenorphine or Suboxone than she was on hydrocodone? Her tolerance will be higher—meaning greater physical withdrawal if she stops the buprenorphine, than she would have had stopping the hydrocodone.

But on the other hand, she tried to stop taking hydrocodone for several years, and couldn’t. She was taking over 4 grams of acetaminophen per day— the other medication present in Norco besides hydrocodone— which is enough to cause death through liver toxicity. And the ups and downs of hydrocodone addiction create a living Hell that eventually demoralizes the person.

I hear from writers who are angry at their physician for getting them ‘stuck on Suboxone’, saying they should have simply tapered off the hydrocodone instead. My answer is that it is easier to SAY ‘I would have tapered of hydrocodone’ than it is to actually taper and stay off hydrocodone!

A doctor seeing the patient I wrote about in part one, or the person above, would face two options:

1. Cause an incidental ‘high’ by administering buprenorphine, and titrating the dose up to a level that eliminates cravings, or:
2. Use an alternate treatment strategy.

Some doctors would opt for the latter, saying they are not comfortable with deliberately intoxicating patients with opioids—something that is unavoidable when starting a low-tolerance patient on buprenorphine (or Suboxone; note that the naloxone component of the medication is irrelevant to this discussion, as it has no action unless injected).

In such cases people are often referred to step-based or other residential treatment centers. I’ve written some pessimistic opinions about those places, but I’m just trying to be accurate. I realize that there are many people dedicating their lives to treating people with addictions in such places—ranging from free, community-supported programs to $80,000 per month luxury rehabs. As dedicated as those people are, the success rate of such programs remains low, and the risk of fatal overdose is present upon discharge. Most people who have gone through residential treatment relapse. And many people have been through rehab multiple times, yet continue to struggle.

Vivitrol, a monthly, injectable form of naltrexone, has been marketed to fill in this space, as a protection against relapse after residential treatment or after several weeks of detox. But for whatever reason, most people opt to forgo that medication, instead placing misguided faith in their own ability to stay clean. So what usually happens is that people with a lower tolerance to opioids repeatedly go through detox, or repeatedly pay for residential treatment, only to return to using opioids. Tolerance increases over time and eventually they present with a tolerance level where Suboxone seems more appropriate.

Assuming, of course, they live that long.

Hydrocodone (Vicodin) Addiction and Buprenorphine

I recently accepted a young man as a patient who was addicted to hydrocodone (the opioid in Vicodin), prompting a discussion about treatment options for someone who hasn’t been using very long, and who hasn’t pushed his tolerance all that high. Perhaps it will be informative to share my thought process when recommending or planning treatment in such cases. In part one I’ll provide some background, and in a couple days I’ll follow up with a few more thoughts on the topic.

Most people who have struggled with opioids learn to pay attention to their tolerance level—i.e. the amount of opioid that must be taken each day to avoid withdrawal or to cause euphoria (the latter about 30% more than the former). For someone addicted to opioids, the goal is to have a tolerance of ‘zero’—meaning that there is no withdrawal, even if the person takes nothing. That zero tolerance level serves as a goal, making having a high tolerance a bad thing, and pushing tolerance lower a good thing.

Tolerance is sometimes used as part of the equation when determining the severity of one’s addiction. But looking at tolerance alone can be misleading. Tolerance is a consequence of heavy use of opioids, and also a cause of heavy use of opioids. Tolerance usually goes up over time, so having a high tolerance probably correlates with length of addiction in some—- but not all— cases. Tolerance is also strongly related to drug availability. A person with a severe addiction, who only has access to codeine, will likely have a lower tolerance than a person with a more mild addiction, who has free access to fentanyl, oxycodone, and heroin.

I think it is more appropriate to measure the ‘severity of addiction’ by the degree of mental obsession that the patient has for opioids. Tolerance is one piece of information in determining that obsession, but tolerance alone can be misleading.

To get a sense of the obsession for opioids, I look at many factors. Has the person committed crimes to obtain the substance? Violent crimes? What has the person given up for his addiction? Has he been through treatment? How many times? How long did he stay clean after treatment? Have his parents or spouse thrown him out of the house, and if so, does he still use? Did he choose opioids over his career? Over his kids?

Answers to these questions provide a broad understanding about the addicted person’s relationship with the substance—an understanding that is necessary when considering the likely success or failure of one treatment or another. It is also important to consider the person’s place in the addictive cycle—i.e. early, likely in denial, cocky, with limited insight– or late, after many losses, more desperate—and perhaps more accepting of treatment.

I am a fan of buprenorphine as a long-term treatment for opioid dependence, as readers of this column know. I consider opioid dependence to be a chronic, potentially-fatal illness that deserves chronic, life-sustaining treatment— and buprenorphine, in my experience, is a very effective treatment in motivated patients. But tolerance becomes a factor, when considering buprenorphine for THIS patient.

Buprenorphine has a ‘cap’ or ‘ceiling effect’ that allows the medication to trick the brain out of craving opioids. In short, as the blood or brain concentration of buprenorphine drops between doses, the opioid effect remains constant, as long as the concentration is above the ceiling level. In order to achieve the anti-craving effects of buprenorphine, the dose must be high enough to create ‘ceiling level’ effects. If buprenorphine is prescribed in lower amounts—say microgram doses— the effect is identical to the effects of an agonist, since the dose/response curve is linear at lower levels.

Buprenorphine is a very potent opioid, and the effects of the medication are quite strong at the ceiling level. Comparisons to other opioids will vary in different individuals, but in general, a person on an appropriate dosage of buprenorphine develops a tolerance equivalent to that of a person taking 40 mg of methadone per day, or approximately 60-100 mg of oxycodone per day.

A person taking even a dozen Vicodin per day has a much lower tolerance to opioids. Such a person who starts buprenorphine treatment will obtain a very significant opioid effect from the drug— unless the dose of buprenorphine is raised very slowly over a number of days. And in that case, the person’s tolerance level would be pushed much higher.

So if our current patient starts buprenorphine, he will have a much higher opioid tolerance if/when the buprenorphine is eventually discontinued. I receive emails now and then from patients who are angry at their doctor for starting buprenorphine, feeling trapped by the considerable threat of withdrawal from stopping the drug. But at the same time, taking hydrocodone and acetaminophen in high amounts creates the risk of liver damage from the acetaminophen, as well as the considerable risks from opioid dependence.

And so the dilemma. Should buprenorphine be considered in such a case?

Uncoupling of analgesia, tolerance, and euphoria from mu-agonists using buprenorphine

I presented this topic at the Atlanta meeting of ASAM a couple weeks ago.  There are too many slides, but the historical stuff was just too fascinating to leave out.  I wanted to demonstrate,  by lining it up on the side, how time has compressed the most critical discoveries to a very short period of time.  In other words, it wasn’t until thousands of years of opium use that the general concept of endorphines and opioid receptors came along.  We can only hope that similar understandings of the biological basis of tolerance and withdrawal will be comparatively soon.

My study shows something truly fascinating– that a partial agonist seems to anchor tolerance at a lower level, still allowing for potent analgesia, but preventing euphoria and dose escalation.  I have used this combination in people with very major surgeries, that are known to be quite painful– i.e. knee and hip replacements, dental surgeries, gallbladder surgery, and median sternotomy.