It is currently Sat Aug 19, 2017 9:40 am



All times are UTC - 5 hours [ DST ]


Our Sponsors





Post new topic Reply to topic  [ 4 posts ] 
Author Message
PostPosted: Sun Nov 22, 2015 12:26 pm 
Offline
Average Poster
Average Poster

Joined: Sat Oct 05, 2013 4:00 pm
Posts: 24
My surgery is scheduled for this Wednesday - three days from now. I saw the anaesthetist on Thursday, and advised her that I take 1 mg of Suboxone and was sent to her by my orthopaedic surgeon to figure out a formula for post-operative pain.

She suggested that, since I have gotten down to 1 mg by alternating my next desired dose with my current dose, I alternate 1 and .5 until the day of surgery to reduce opioid tolerance. I was quite surprised, as my Sub doc would expel me for this, but with another dr. orders, I think he'll be okay, especially if I bring in my "unused" Suboxone (that annoys me, as I have to give them what I didn't take, and if I suggest that I take what I have left, I get threatened with having to go in to be dosed everyday, and having my "privileges" taken away).

She stated that they will use hydromorph (Dilaudid) for pain. I will not quit the Suboxone whilst taking the hydromorph, but am also fearful that I will get too much relief because of the low dose of Suboxone.

Also, I am fearful that the hydromorph will displace some of the buprenorphine while I am on it. Am I going to need a "loading dose" when I am done with this? I took 4 5-mg shots of Morphine in hospital and threw me into withdrawals at about 5 mg Suboxone. At a dose that is somewhere between 10 and 20 percent of my previous experience, I don't know what to expect. She also told me to not worry about discontinuing NSAIDS, as she felt the reduction in Suboxone would cause back pain (I have a messed up back).

The surgery will consist of hardware removal on the radius, realignment of the bones, bone graft, insertion of new hardware, and a carpal tunnel release. I've had all before, except the carpal tunnel release, which I think will be minor, comparatively.

My concerns are two-fold:
1) How do I keep my opiate receptors "at bay" and continue with Suboxone while taking the dilaudid (I know it can be done - I've read Dr. Junig's presentation and his writings, but he talks of keeping patients at the 4 mg mark, which I understand to be around where the ceiling lies)?
2) Should I worry about bleeding in the OR? The scar from the incision is already a good four inches long, and he is going to add at least an inch to this for the carpal tunnel release. I take about 800-1600 mg Ibuprofen per day.

If anybody has any answers, please chime in! I am so scared...


Top
 Profile  
 
PostPosted: Sun Nov 22, 2015 7:12 pm 
Offline
Site Admin
Site Admin
User avatar

Joined: Sun Feb 24, 2008 11:03 pm
Posts: 1543
I don't know if she is crazy. But a week is not enough time to lower opioid tolerance--- even if you were to stop buprenorphine completely. I don't think that the reduction she suggests would hurt anything either. You will make a slight reduction in your blood level of buprenorphine, and as you suggested, it MIGHT result in less blocking of mu receptors by buprenorphine-- allowing the Dilaudid to have a slightly-greater effect. But I don't think the decrease is enough to create a noticeable effect.

My concern is that you won't get enough Dilaudid. No matter what happens to your buprenorphine dose, you will have a high opioid tolerance, and SOME blocking by buprenorphine, when you have your surgery. So you will need double or triple the usual amount of Dilaudid-- and I hope she made note of that. So instead of 4 mg, you will need 8 or 12 mg per dose-- or even more if you have major surgery.

If you take buprenorphine every day, I do not believe you have to worry about precipitated withdrawal--- even if your dose is 1 mg per day alternating with 0.5 mg per day.

The effect of ibuprofen on platelets, unlike the effect of aspirin, is reversible-- so if you stop NSAIDS for 24 hours, they shouldn't cause bleeding problems.

These are all 'educated guesses'.... but they are consistent with what I've seen in my own patients over the years. Good luck!


Top
 Profile  
 
PostPosted: Fri Dec 18, 2015 3:47 pm 
Offline
Average Poster
Average Poster

Joined: Sat Oct 05, 2013 4:00 pm
Posts: 24
Dr. Junig, if you knew how many people in Canada I have raved to about you, you would think I had taken out a PSA. Thank you.

The surgery is done, and there were some interesting things that occurred. First off, I reduced to .5 mg preoperatively for five days. I don't remember for certain if I dosed the day of surgery, but I believe I did.

Pursuant to the pre-op with the anaesthetist, the doctor ordered 4-8 mg s/c q4h prn. They started with 4 mg, fortunately, as my respirations fell to 4 per minute. I was as high as a kite. As we all know (sadly), Dilaudid is a short acting med, so at the next administration, I asked for 2 mg, which kept the pain at bay and was not as intoxicating. With this said, even at this dose, I must have had some level of euphoria, as at some point, I decided I didn't want to be there anymore, so grabbed my bags (this was forearm surgery - three, wait four, procedures) and walked to the drug store to buy makeup for my daughter.

The doctor ordered 6-8 mg p/o q4h. Being a good Suboxone patient, I called the clinic the next morning to advise them that I had been ordered Dilaudid, but was taking the Suboxone concurrently (note the oral ingestion rendered no euphoria, whatsoever). I was told, "Well, you can stay on the program and surrender the Dilaudid, or you can quit the program. You're not allowed to have opiates." I was dubious that the pharmacist would count the meds turned in, so kept about 20 2 mg tabs. I figured that if I took 4 mg p/o with 500 naproxen and 1000 of acetaminophen, it would work. It sort of did. It helped.

So, I had SOME pain control for two days. A friend of mine brought me some medicinal stuff called Phoenix Tears, which seems to just be cannabis oil, and that actually helped much more than any opiates. I took that for a few days, and was then good on NSAIDs and Tylenol.

Lessons learned:
1. I am way below the ceiling, and need to be aware of this. Should I need to use opiates in the future, I will ask that I be brought up to a higher dose of Suboxone while the opiates are being administered.

2. Unfortunately, I have learned that I can achieve euphoria at my dose. I will have to be extra vigilant.

3. I've heard it before, but can attest that the combination of NSAIDs and acetaminophen seems to potentiate analgesics.

4. The people at my Suboxone clinic are not very sympathetic (nor consistent - a friend of mine was in a collision last summer and was kept on Fentanyl).

5. I am not as certain that I am ready to go off of Suboxone as I was pre-operatively. Feeling that "high" again was too pleasurable, and, even if its psychosomatic, being on Suboxone makes me feeling like I have opiate armour.

Thank you, Dr. Junig, for taking the time to respond to my post. I thought you would find the euphoria, pain control, and decreased respirations at the decreased dose interesting, hence this response.


Top
 Profile  
 
Our Sponsors
PostPosted: Fri Dec 18, 2015 4:16 pm 
Offline
Moderator
Moderator
User avatar

Joined: Thu Feb 23, 2012 4:42 am
Posts: 4127
I am glad, at least, that your pain was controlled! What a weird experience!

Your clinic is beyond ridiculous! They should be ashamed of themselves for threatening to kick you out when you kept them informed of everything and had major surgery!

I'm glad the guidance that Dr. Junig gave was helpful to you. :)

Amy

_________________
Done is better than perfect!


Top
 Profile  
 
Display posts from previous:  Sort by  
Post new topic Reply to topic  [ 4 posts ] 

All times are UTC - 5 hours [ DST ]


Who is online

Users browsing this forum: No registered users and 1 guest


You cannot post new topics in this forum
You cannot reply to topics in this forum
You cannot edit your posts in this forum
You cannot delete your posts in this forum
You cannot post attachments in this forum

Search for:
Jump to:  
Our Sponsors
Suboxone Forum latest topics RSS feed Subscribe to the entire forum
 

 

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

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

Powered by phpBB® Forum Software © phpBB Group