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 Post subject: oral surgery
PostPosted: Tue Dec 29, 2009 12:17 pm 
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I am scheduled for oral surgery next friday to have 6 teeth extracted. I'm really in a bad situation because I don't know how to tell the doc that I'm gonna need the very substance that I'm addicted to and alot of it for that matter. I mean I can only imagine my reaction if I were in his shoes. I have had teeth removed in the past and I was in alot of pain so I know that this is going to be no different, not to mention the fact that they are taking 6 of them at once. My tolerance is very high because I'm on 32mg of suboxone a day so I know that I'm gonna need some strong pain killers to be comfortable. How can I make the doctor understand this and also make him comfortable with prescribing me a dose that would probably kill a normal person? Please, anyone that can give me some insight in this matter I would greatly appreciate it.


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PostPosted: Tue Dec 29, 2009 12:41 pm 
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Ask your subs Dr to contact your dentist to coordinate your treatment. That is the best and safest way for the procedure.


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PostPosted: Tue Dec 29, 2009 12:55 pm 
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thank you for your reply freedom, but to be honest with you I don't really think that my sub doctor truly knows what its gonna take for me to get some relief from the pain.


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PostPosted: Tue Dec 29, 2009 1:35 pm 
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I had a similar problem while on methadone... my dentist is an oral surgeon licensed for anesthesia and he knew exactly what to do because i told him in advance. Call your dentist and tell him you are on Subs and if he has the anesthesia license... he will know what to do.

If so he will probably put you on demoral and inject as needed. Just as long as he knows your situation in advance... there will be no problem. The only difference between you and me is the subs vs meth so you may need to be off the subs for 24-36 hrs in advance. Definitely will need to wait for that period afterwards to re-introduce the subs back to your body


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PostPosted: Tue Dec 29, 2009 2:14 pm 
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:?: ok I understand what your saying about the anesthesiology thing, but I'm confused about what you meant by the demerol injections. Do you mean that every time that I start to feel pain that I will have to go into his office? or will he send me home with injectable demerol?
:?:


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PostPosted: Tue Dec 29, 2009 2:35 pm 
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From what I have read, you may want to be off of Suboxone for quite a bit longer than 24 hours. Under general suggestions, I usually see at least 48 hours if not more like 72 for the dose you are on. Some doctors also prefer to have you stop Suboxone and transfer to a true opiate pain medication as far as one week in advance. This will keep you from getting withdrawals as well as sort of "pre-medicate" you for the procedure.

The key to all of this will be HONESTY and COORDINATION with both your Subs doctor and your dentist. You will need to lead the charge to coordinate with both of them for this to work for you. BE HONEST with them ABOUT EVERYTHING. Let them know that this is not a way around treatment or a "chance for you to get high" but rather a very legitimate pain management issue for real, honest pain. Well educated, modern doctors will totally understand that just because you are an addict and in treatment DOES NOT mean that you should not be treated for your pain. To a point, the younger your providers are, the better chance you'll have. If they are in their 50s or 60s and have not kept up with current trends, they may not "get it". If that ends up happening, it is your job to, politely, but firmly make sure that they come up with a plan that will work for you. In turn, tell them that you are going to be 100% honest with them and work with them 100% - and that includes getting back on your Suboxone just as soon as you can.

While we all know there are a large variety of good and not so good docs out there, most all of them really do want to do the right thing. You might be amazed at how much more power you actually have in all of this. Convince them that you want to do the right thing here and you have a much better shot at having the right thing done for you.

I certainly hope that helps. Please let us know how it goes.


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PostPosted: Tue Dec 29, 2009 5:45 pm 
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Thanks alot donh!! What you said is exactly what I had planned on doing, and being honest I believe is the most important part. But, the honesty is precisely what I am afraid the dentist won't understand. Hopefully he will be a modern type of doctor like you said and will understand and be willing to do what it takes. And don't worry I will definitley let you all know what happens.
Again thanks so much.


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PostPosted: Tue Dec 29, 2009 6:00 pm 
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Hello...All the info above is good. I just would like to add that maybe you try to cut down your dose asap and try to do the few days without sub at like a jump from 2-4mgs. I have heard that this will be better for your pain control with whatever meds you get. As I understand it, the higher the dose even with the ceiling effect (whatever dose that actually is) makes blocking full agoinists even stronger (i.e. if you are on 1 or 2 mg, then it won't take as much pain meds to relieve pain compared to being on 32mgs, just some insight). I know you are on 32 mgs and it might be a bit hard to get down that low, but if you can do that as soon as you can and then make that few day jump. Of course, jumping even earlier and then going on a full agoinist will probably be the easiest for you but the hardest to get your Dr to do depending on the situation. Let us know what happens please. Good luck I hope everything works out!

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PostPosted: Tue Dec 29, 2009 6:42 pm 
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jkrawlings32 wrote:
:?: ok I understand what your saying about the anesthesiology thing, but I'm confused about what you meant by the demerol injections. Do you mean that every time that I start to feel pain that I will have to go into his office? or will he send me home with injectable demerol?
:?:


I'm referring to my dentist initiating IV [while I was in chair before he started procedure] and injecting demerol at intervals [as needed] for calming effect and surgical pain. He also used local numbing at tooth extraction site. I was conscious even though he used oxogen mask and blood pressure arm wrap. This was for 3 extractions followed by dental implants. I was on methadone maint at time. He gave me vicodin for after care pain.

He was aware of the fact I would need extra narcotic pain meds [during and after surgery] because of "Cross Tolerance" factor which is well known among specialists who treat MMP.

Dr. Thomas Payte [Director of NAMA] provides and an online paper/form avaliable to print out and give to prospective surgeons who are unaware of the fact that maintenance patients need more [rather than less] narcotics for pain mgt and surgery. This is for Methadone Maintenance Patients [MMP] but could possibly apply to Subs patients too??

My wife was in waiting room and took me hom afterwards.


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PostPosted: Thu Dec 31, 2009 3:00 am 
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You probally won't like my post.......I had 6 teeth extracted while on Suboxone...I want to be free of opiates........I can't stand this kind of pain...and would need what you need.....but your behavior would be DSB (drug seeking behavior) by any denitist with a pulse. I told my dentist I was on suboxone...and was addicted to opiates...Even though he offered percocet and norco...I chose Ibuprofen 800 mg...your laughing now..........but that is ok...I want to be free of this disease......sure I was in pain..but I survived and I am ok today.You can do what you belive is the right thing to do but can you do this without those meds......it's up to you......I am only sharing my experience....you do whatever your big enough to do......good luck......


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 Post subject: Raise
PostPosted: Thu Dec 31, 2009 1:26 pm 
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I try not to take anything personal at this forum because I believe a big part of what is valuable here is both educational and informative.

I was on MMT at the time of my surgery so Suboxone and long term recovery was irrelevant [to me] at the time.

And... I was scheduled for dental implants with bone grafts surgery... Therefore I was extremely concerned about the [well researched & documented] "cross tolerence" pain effect for surgery and acute pain mgt while on MMT. I was more than willing to take whatever my dentist recommended for pain control.... before, during and after the surgery.

BTW I've had other surgeries including the removel of seven shell fragments from my body while in Vietnam... but that was nothing compared to the implants/grafts... I had also had two previous kidney stones... so I know a little about pain.

Here is some info regarding acute pain mgt for addicts from: http://www.drugpolicy.org/library/methpayt.cfm

==============

a. Acute Pain

Methadone-maintained patients occasionally require medical, surgical, and dental procedures that are provided or performed away from the methadone maintenance program. When the conditions or procedures cause pain, serious errors in patient management commonly occur. As a result, pain is either not treated or seriously undertreated.

The practitioner often believes that a patient taking 80 mg of methadone daily could not possibly need anything else for pain. This is absolutely incorrect. It should be crystal clear that the methadone-maintained patient is fully tolerant to the maintenance dose of methadone and thus experiences no analgesic effect from this narcotic at the stable dose.

Another common clinical error is based on the belief that any exposure to opioid agonist analgesics will somehow aggravate the addictive disorder. There is some basis for this belief, in that relapse to illicit opioid self-administration has occurred when former heroin addicts, in remission or recovery, have been given narcotics. In the authors' experience, these situations most often occur when the prescribing practitioner is unaware of the history of opioid dependence and the patient takes an active role in seeking narcotics, justified by the temporary pain condition. In 1980, Kantor and coworkers compared a group of methadone maintenance patients who were exposed to significant amounts of narcotic analgesics in the course of hospital treatment with a group of methadone maintenance patients with no such exposure. The patients were followed for a mean of 20 months, with the narcotic-exposed group showing no differences to controls.

The inadequate treatment of pain in methadone-maintained patients commonly leads to disruptive behavior by angry and frightened patients and discharge against medical advice, often to the detriment of the patient's health (Zweben and Payte 1990).

The principles of managing acute severe pain in the methadone-maintained patient are quite simple:


Do not interrupt daily methadone maintenance.

The patient's dose should not be changed, whether by oral or intramuscular routes, although it may be divided: 50 percent of usual dose before and 50 percent after surgery, intramuscularly administered.

Discuss pain management with the patient and give assurances that he or she will be afforded adequate relief.

When nonnarcotic analgesia is not effective, short-acting opioid agonist drugs should be used in higher and more frequent doses against the background of continued methadone maintenance.

Do not use agonist/ antagonist drugs such as pentazocine (Talwin), butorphanol tartrate (Stadol), nalbuphine hydrochloride (Nubain), and buprenorphine (Buprenex). These agents may precipitate AS in the methadone-maintained patient.

Change to nonnarcotic agents as soon as practical.

Avoid prescribing for self-administration.
Patients may request a temporary increase in methadone dose during an episode of pain. This practice is not uncommon. However, increasing the daily methadone dose may afford only approximately 6 hours of analgesia. Short-acting opioid analgesics are appropriate and effective in methadone maintenance treatment patients if used properly. Because of the established cross-tolerance, the short-acting opioid agonist agents may require larger-than-usual doses and more frequent administration. Attending physicians may need both firm guidance and reassurance from experienced addiction medicine professionals because the attending physicians are not accustomed to using such large narcotic doses. Still others may become judgmental, angry and punitive and withhold medication. Many unpleasant situations and much unnecessary suffering can be avoided by discussing pain management plans with both patient and physician before surgery whenever possible.


Here is additional info:
http://www.atforum.com/SiteRoot/pages/c ... pr98.shtml

This is a copy of the letter offered by Dr Payte as a guide and used by MMT patients scheduled for surgery.
http://www.methadone.org/namadocuments/ ... ement.html

Hopefully, there is a similar letter [somewhere online] related to Bupe for uninformed doctors to consider prior to surgery/treatment. If so... the content would be significantly different due to Subs/ "ceiling effect' and "precipitated wd".

Unfortunately most Med Schools only offer an avg [TOTAL] of nine hours related to narcotics addiction and pain mgt. This info was provided to me by a Psychiatrist who was also a recovering addict.

I've not had surgery while on Bupe so I cannot relate to that experience...


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