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PostPosted: Wed Mar 31, 2010 10:51 am 
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I'm going in for another minor surgery on April 19th. This forum has given me so much information on going from Suboxone to short-acting meds and back onto Subs - I can't thank all of you enough.

My fear is - regardless of any ID card from NAABT - that my surgeon won't give me enough pain meds to overcome my tolerance. I fear either inadequate pain relief or withdrawals from not enough.

So I went in search of something "official" that I could share with my doctor about treating acute pain in patients taking Suboxone. It looks like I found it! It's from NIH (National Institutes of Health), so it's from a reputable source (as far as I know), and the article is called "Acute Pain Management for Patients Receiving Maintenance Methadone or Buprenorphine Therapy".

Here's the Abstract: "More patients with opioid addiction are receiving opioid agonist therapy (OAT) with methadone and
buprenorphine. As a result, physicians will more frequently encounter patients receiving OAT who develop acutely painful conditions, requiring effective treatment strategies. Undertreatment of acute pain is suboptimal medical treatment, and patients receiving long-term OAT are at particular risk. This paper acknowledges the complex interplay among addictive disease, OAT, and acute pain management and describes 4 common misconceptions resulting in suboptimal treatment of acute pain. Clinical recommendations for providing analgesia for patients with acute pain who are receiving OAT are presented. Although challenging, acute pain in patients receiving this type of therapy can effectively be managed."


http://www.ncbi.nlm.nih.gov/pmc/article ... s17732.pdf

This is a GREAT paper. Simple, clear, and concise. Now I just need to figure out a way to get my surgeon to read it without seeming patronizing. Any thoughts?

I'd love to hear Dr. Junig's take on this paper.

Melissa

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PostPosted: Thu Apr 01, 2010 12:07 am 
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Hatmaker: This is a great find! It is very well researched and written and I have no doubt would be respected by physicians and healthcare providers that we might give it to. Hell, they have cited over 100 references! The journal itself is well respected. This is about as good as it gets when it comes to peer-reviewed journals. The only problem is, and my only disappointment comes from, the fact that I'm not sure this paper is providing us with many new or good answers for Bup. in the face of treating pain.

The parts that talk about pain and opiate dependence, the many common misconceptions, and the general recommendations, I think are very helpful. Unfortunately, when they get to the Bup section, the first sentence may speak the loudest and say the most:

Clinical experience treating acute pain in patients receiving maintenance therapy with buprenorphine is limited.

In other words, they didn't have a lot to work with. While Bup is not a new medication, using it for treating addiction is still pretty new. They go onto list several "possible approaches" to deal with the problem. Even those two words show that they are not certain as to what works best. In the end, they offer the following four suggestions:

1. Continue the current dose of Bup and just give a full agonist on top of it to treat the pain.
2. Use Bup as the pain med, but divide the dose into three or four times each day.
3. Stop the Bup and just use a full opiate to treat the pain.
4. Switch the Bup patient to Methadone and use a full opiate for the pain.

Unfortunately, I'm not sure that from the experiences I've read from patients that any of these have worked with overwhelming success. Since we once again don't have any actual studies that tests these various suggestions, we don't really have any scientific proof which ones work well, which ones don't work well, and which ones work the best. In the end, they are somewhat saying: There is not a lot of experience with people who take this drug and then have to treat pain, and we are not sure what will work, but here are the four things that may work the best.

When looking at each one, it is rare that No. 1 works very well from what I have read and people report. Pretty much anyone that is on any significant dose of Bup says that it blocks full opiates very well. No. 2 seems to work for some people but even in the article they talk about why Bup is not a very good alternative for treating pain for patients that take it daily. No. 3 seems to be the one that I have seen people report the most success with and the one most doctors seem to try. I have never heard of No. 4 nor have I read anyone post that this was attempted with them. In theory it seems like it might be workable. It may be worth a try. Perhaps someone here has experience with this method.

I also found it interesting that the authors of this paper recommend that if patients use No. 3, that they again use an induction protocol when returning to Bup maintenance. I find this interesting because a few weeks ago several people here reported that they just went back to using Bup without again going into withdrawals and in fact several people claimed that their physician told them that they didn't need to go through the induction process again. This paper would seem to contradict that.

I'd really be interested in hearing what Dr. J thinks of this paper. Perhaps he is already aware of it?

Of course, the best was to go about all of this would be to assemble a couple hundred Bup patients that require surgery and enroll them in a study. Have 25% of them use one of the four suggested courses of action and then see which patients report the best pain relief. Unfortunately, such a research study is not likely to be undertaken anytime soon. Until it is, all we can do is give one of these four ideas a shot and hope for the best - or someone needs to come up with a fifth or sixth idea that might work better.

What I'm most excited about with this paper is all of the additional information that is included. If nothing else, the section on misconceptions should be mandatory reading for healthcare providers that find themselves taking care of Bup patients who also really do have legitimate pain!


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PostPosted: Thu Apr 01, 2010 8:23 am 
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Melissa,

This is an AWESOME article!!! I know I will be printing it and giving it to my doctor. Also, I think maybe you could talk to the moderators and see if they can make this a sticky under suboxone and surgery forum. I don't know where there is any better information and I would hate to lose track of this one.

Cherie


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PostPosted: Thu Apr 01, 2010 9:45 am 
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I agree with you on Item #3, donh. I'm thinking perhaps the need for a re-induction would depend upon how long the patient has been taking the short-acting pain meds for acute pain. Because I know alot of people have gone directly from pain meds back on subs. In fact that's what my doctor advised - to only wait 12 hours after taking the last pain med.

My doctor/surgeon is an hour away and I need to decide whether to mail her a copy of this or drive down and drop it off in person. Because the last time she did a procedure on me she SAID she knew about suboxone, but in recovery they just didn't have a clue. At the very least I'm bringing a copy of this article with me to the hospital.

I'm just surprised I was actually able to find this!

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-I'm only responsible for what I say, not for what you understand.


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PostPosted: Fri Sep 10, 2010 6:56 pm 
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Awesome article hatmaker - good job!

J

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

  • Board Certified Psychiatrist
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