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 Post subject: Getting a new nose!
PostPosted: Fri Nov 20, 2015 4:18 am 
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Hello,
I am hoping suboxdoc can offer me some advice. I have decided to get a new nose. For both functional and cosmetic reasons, I'm getting a nose job! My plan was to stop taking subs 3 wks before surgery and instead take short acting opiates so I can still work and function up until surgery. From what I have read, pain subsides around day 4. I have no idea if the pain is mild or moderate.
What would you advise as far as when to stop subs and when to reintroduce subs and or if you think subs may help with post op pain?
Thanks so much!


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 Post subject: Re: Getting a new nose!
PostPosted: Fri Nov 20, 2015 10:06 am 
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Hey Katipo,

Congrats on the new nose!! I bet that's exciting and scary at the same time. It's definitely a question for Dr.J cause that's something I know nothing about. I just wanted to wish u luck and I think it's awesome that u have the opportunity to do this for urself.

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 Post subject: Re: Getting a new nose!
PostPosted: Fri Nov 20, 2015 11:10 am 
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Hi Katipo, I too don't have answers but just wanted to wish you all the luck! Very exciting! Wishing you the best!


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 Post subject: Re: Getting a new nose!
PostPosted: Fri Nov 20, 2015 11:59 am 
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Hello Katipo,
Dr Junig has written several posts in the Talkzone on surgery with suboxone.

If you would go over there and search for : Opioid Analgesia Without Addiction" and "Buprenorphine plus Hydrocodone", it will give you a idea on how he does this with his patients.

There is no stopping of the sub treatment. A lowering of the dose in the 4 to8 mg range with a higher dose of Oxy csn gkve post op pain relief and most importantly there is no need to restart treatment with bupe...

He explains kt beeter than I, but ive known two people in our clinic who have done this with great results. I understand that this is not the "normal " way but there is also a information sheet you could print off to take to your drs..

Goood luck, and just know you ll be ok in the end.

Razor...


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 Post subject: Re: Getting a new nose!
PostPosted: Fri Nov 20, 2015 1:50 pm 
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Make sure the post op nurses know that you are opiate tolerant! Otherwise you will wake up in a lot of pain. Good luck with your new nose!

Amy

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 Post subject: Re: Getting a new nose!
PostPosted: Tue Nov 24, 2015 4:13 am 
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You are all beautiful, Thankyou so much for your kind and informative replies.
Razor, I appreciate you pointing me in the right direction, answered all my questions!
Xx


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 Post subject: Re: Getting a new nose!
PostPosted: Wed Nov 25, 2015 9:19 pm 
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Thanks again Razor! I've used both approaches to post-op pain-- stopping buprenorphine vs. continuing buprenorphine. From my experience, the latter is much easier. If there is a debate over the issue, I'm clearly losing; an NIH 'consensus paper' from several years ago recommended stopping buprenorphine, using agonists, then stopping the agonists, going through 24 hours of withdrawal, then restarting buprenorphine. I have no idea how much experience the people have, who came to 'consensus' on the issue. I'm never asked my opinion, which I assume is because I don't belong to any of the societies, don't participate in clinical trials, and don't get along well with other doctors.

There was also an 'article' in a magazine for addiction docs a few months ago, that stated that the proper approach is to stop buprenorphine. I put article in quotes because there was no study behind the opinion, and the magazine is not peer-reviewed or screened for accuracy. Anyone who took the time to submit content could have put out entirely different information.... and I just don't have time to write content for the throw-away journals. I wondered, after seeing this one, if I should find the time--- as I realized that most doctors read things like that and actually believe that they are true.

As I've written in the blog, I've had patients go through the most painful surgeries out there-- including nephrectomy, thoracotomy, rotator cuff repair, knee replacement, and open cholecystectomy. From my anesthesia days, I know that these surgeries hurt the most, post op. I've had patients go through c-sections, abdominal hysterectomy, and sternotomy too-- which are major surgeries, but don't require the incisions through layers of muscle that typically cause the most post-op pain.

In ALL of those surgeries, patients have done well using the approach that I favor-- i.e. reducing the dose of buprenorphine by half a day before surgery, continuing that dose throughout the entire post-op period, treating pain using oxycodone, and then resuming the full dose of buprenorphine when opioid agonists are discontinued. I think that IV fentanyl by PCA probably works better than oxycodone for inpatients, IF you can find a cooperative surgeon or anesthetist to manage the PCA. The ideal situation for major surgery is to have the patient in the ICU post-op so that the PCA doses can be raised to appropriate levels to out-compete buprenorphine. And if at all possible, the nurses should be lobotomized, so that they are able to stop saying 'that dose is high.... that dose is high....'-- and instead focus on the patient's vital signs. Respiratory rate is a very reliable measure of the degree of 'narcotization'--- and if the nurses pay attention to respiratory rate and pain scores, instead of micrograms of fentanyl, things work out very well.

I'm getting sarcastic. Sorry about that.

I have prescribed oxycodone post-op in doses ranging from 15 to 30 mg. I've never had to go over 30 mg every 3-4 hours-- and usually 15 mg works fine. The amazing thing about the approach is that in the few cases I've had where the need for narcotic extends beyond a few days, such as in a patient whose rotator cuff repair tore off the bone three times after 3 separate surgeries, the pain relief showed no sign of tolerance over at least 6-8 weeks. During the entire time, the patient continued 4 mg of buprenorphine per day. After each surgery, she tapered off agonists after 7-10 days. And each time, after repeat injury and surgery, she went back to the same dose of oxycodone in addition to buprenorphine. Imagine if she needed to go on and off buprenorphine for each of those surgeries!

But the most interesting part is how buprenorphine appears to 'anchor' tolerance-- which is totally predictable given the phenomenon of precipitated withdrawal. As long as buprenorphine occupies the receptor FIRST, the addition of an agonist will not precipitate withdrawal. The euphoric effects of opioids are also blocked by buprenorphine, so that patients on the combination always say the same thing: the pain was relieved, but it didn't 'feel' like oxycodone.

I'm writing way too much, and my family is wondering where I disappeared to. Good luck with the surgery-- and have a Happy Thanksgiving, everyone!


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 Post subject: Re: Getting a new nose!
PostPosted: Sun Nov 29, 2015 1:40 am 
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Thankyou so much DR J, definitely more at ease with how to manage this. I appreciate your input once again!
KAT


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Fond Du Lac Psychiatry
Dr. Jeffrey Junig, M.D., Ph.D.

  • Board Certified Psychiatrist
  • Asst Clinical Professor, Medical College of Wisconsin

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