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PostPosted: Wed Aug 07, 2013 6:03 am 
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I recently had surgery on an oral mass inside my cheek. The mass was causing pain and the surgery I was scheduled to have would be under general anesthesia (propofol for those pharmacology majors.) A couple weeks prior to my surgery I met with my psychiatrist (who prescribes my Suboxone - 8mg/2mg film 3 times / day) and the following was decided:

1) Consent given for communication between oral surgeon and psychiatrist.
2) Decision made to switch to agonist opioid analgesics and discontinue Suboxone.
3) Have surgery as scheduled and increase opioid analgesics as needed.
4) Once recovered from surgery discontinue opioids and resume Suboxone.

This is what happened:

(Bear in mind I have been taking a total of 24mg buprenorphine/day for over 3 years...) I was prescribed hydrocodone/APAP 10/325 (Norco) and oxycodone HCl 10mg. The Norco was 2 tabs every 4 hours (max dose) and the oxycodone was 10mg every 6 hours as needed for breakthrough pain. What I found was that after the 3rd day of no Suboxone and the above opioids I experienced growing withdrawal symptoms. On day 4 I was ok'd to double the oxycodone to 20mg every 6 hours as needed but it had no effect. Luckily the trauma from the oral mass had subsided so I was no longer in pain and I immediately resumed my regular Suboxone dosing.

3 days before my surgery I started to taper by 8mg/day off the Suboxone. I underwent the procedure and awoke in the recovery ward with a good deal of pain. I rated it as a 5 out of 10 but for us opioid addicts we know that a genuine 6 or above would mean something nearly excruciating. Luckily I had made sure that the anesthesiologist, charge nurse, surgeon - EVERYONE know that I was and had been on Suboxone for years and that a good deal of the drug was still acting as antagonist to any agonist they could administer. The recovery nurse kept giving me injections of fentanyl and Dilaudid. It took 250 mcg of fentanyl and 12.5 mg of Dilaudid to reduce the pain to a 4 out of 10. My psychiatrist and I had met the day before the surgery and I was given a prescription allowing me to take a substantial amount of oxycodone if needed.

Luckily I had an excellent surgeon and the procedure was mild in terms of expected recovery time and discomfort. The night after the surgery I resumed my Suboxone at 32mg/day (max) and was also given Toradol and Valium.

In short my experience taught me that:
1) Tapering off Suboxone is a process that must be slow, gradual and 'baby-step' in nature.
2) I completely underestimated the extent to which my opioid receptors had been altered from years of buprenorphine use; even potent mu receptor agonists administered IV produced a small amount of analgesia but with none of the euphoria I used to experience years ago when I was actively using.
3) PLAN AHEAD PLAN AHEAD PLAN AHEAD! Had this surgery been major (i.e. knee replacement) it would have had to be rescheduled because in order for adequate analgesia to work I would have had to be off Suboxone and transitioned to a full agonist (i.e. methadone) for WEEKS before the operation. This experience has also caused me to have documentation in my chart and on my person that I take Suboxone; if I had to have major emergency surgery I would have to be sedated with something like benzodiazepines and a PCA pump and remain an inpatient for a while in order to recover properly.

I hope this hasn't been too much of a 'drug-a-log' but I know when I was researching information prior to my surgery I wanted personal experiences so I could have a better idea what to expect. I am also VERY lucky in that I have a great psychiatrist with whom I share respect and trust.

If you are reading this and would like more technical information on my experience please message me as I have a degree in biochemistry and learning pharmacodynamics is interesting to me (dorky, I know.)

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Feel free to send me a private message if you would like to talk. I have a great deal of experience with psychopharmacology, recovery and healthcare systems.


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PostPosted: Wed Aug 07, 2013 8:40 pm 
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Reading about all you went through was encouraging. It is usually just the opposite of your experience, meaning, most Suboxone users get no relief at all from the opioid pain meds. The fact that your doctor was willing to let you have such large doses is a mini miracle in my book. In all the years I've been here there has been only one other who had a similar experience.

Mine was just the opposite. My surgeon would only give me Lortab 10's at 1 per 4-6 hours and then 1 script for Percocet (30). Trying to discuss it with him was impossible. My Suboxone doctor agreed that I needed to be on stronger drugs but convincing my surgeon was not successful. And I was only on 1 mg when I needed surgery. Even at that low dose my tolerance was still sky high. And like you, I told everyone that I was on Buprenorphine but not one nurse even heard of it. My anesthesiologist was okay and knew what to do. I got the Jackson Juice too.

Knowing that things worked out well for you gives me hope for any future pain issues. (I hope never)

And also let me say: Welcome to the forum!

rule

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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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