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.
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.
I have received a several emails over the past few years from people who experienced deteriorating dental health while taking buprenorphine or Suboxone. I also have patients in my practice who have had extensive dental work, and wonder if Suboxone is to blame for their cavities or other problems.
I wrote about this issue several years ago. At that time I wrote that there was no evidence that sublingual buprenorphine or Suboxone cause or accelerate tooth decay. After writing the article I received a number of angry emails from people who insisted that I was wrong.
Let’s step back for a moment to highlight the difference between thinking something vs. proving something. Some people misunderstood my comments about tooth decay and Suboxone, thinking that I was arguing that Suboxone does not harm teeth. That was not what I wrote. My point was that as of that time, there was no evidence that Suboxone or buprenorphine caused tooth decay. When I write about the science of buprenorphine, I try my best to distinguish between what I think is true vs. what was established through scientific study.
I recently met with a patient who has had extensive dental work over the past few years, the same time that she was taking sublingual buprenorphine. She asked if I thought that the two were related. I made a few comments (that I’ll be getting to), but also promised her that I would do a literature search, to see whether any connection has since been established. Ironically, a case report of a woman on Suboxone who required extensive dental work was just published yesterday. The case report is in the latest issue of The American Journal on Addictions, and the same case is cited in the October 20, 2012 edition of Reactions Weekly. This latter citation is a newsletter that follows multiple sources for any report of adverse drug reactions, described in more detail here.
The world of science is not efficient. Knowledge moves forward slowly, based on findings amassed from many studies, often repeated multiple times. Case reports are not intended to prove something. In fact, case reports are often unusual clinical examples that defy the norm. They are often published to point out an area that deserves more study.
I cannot copy the case report here because of copyright laws. But the case described a 35-y-o woman who used oxycodone for about a year at doses up to 160 mg per day, and then went on buprenorphine/naloxone. After 18 months, her dentist told her that she had extensive decay of 4 molars requiring root canal. She reportedly had minimal history of dental problems before starting opioids or buprenorphine.
The author of the case report hypothesized that if there is a connection between Suboxone and tooth decay, one reason could be xerostomia, i.e. dry mouth, caused by buprenorphine. The lack of saliva was my thought, too, as a mediator of any possible effects of buprenorphine on teeth. Saliva serves an important role in dental health, including rinsing away food particles and acting as a buffer. The patient in the case report did not report a dry mouth, so the author pointed out that all opioids have some ability to suppress the immune response, and perhaps buprenorphine and/or naloxone reduce the immune response, allowing for greater destruction of teeth by bacteria.
The case report, surprisingly, did not say which buprenorphine product(s) the patient had used, e.g. tablets, film, or generic buprenorphine.
What needs to happen next is for someone to do a case-control study of patients on buprenorphine, to see if they are more or less likely to have tooth decay. The most valuable study is usually a prospective, randomized clinical trial; that would not be proper here, since it would not be appropriate to randomize subjects to buprenorphine vs. no buprenorphine. But a close second would be a case controlled study, where patients on buprenorphine are matched to ‘controls’ with similar characteristics— age, sex, eating habits, income level, education, etc.– and the dental outcomes are followed forward over a number of years. A less-costly, less-reliable study is one that looks backward, comparing patients on buprenorphine with those not on buprenorphine to see which group has a higher incidence of dental caries.
We are not much better off at this point in our knowledge of whether Suboxone or buprenorphine predispose toward tooth decay. The case report only mirrors what I see in my practice. But as I often tell patients, I have other patients who are not on buprenorphine or Suboxone, who have tooth problems. I also have patients on Suboxone with great teeth. Hopefully some ambitious PhD candidate will sort through the issue soon.