An Anesthesiologist's Perspective

Can I have anesthesia on buprenorphine or methadone? Will I get enough pain medication? Will I have recall during surgery?
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An Anesthesiologist's Perspective

Post by PremierHealth » Tue Nov 05, 2019 12:52 pm

I am a board certified anesthesiologist and a board certified addiction medicine specialist. Over the past 2 decades, I've had to adjust and readjust both of my practices to help patients thrive through surgery without any additional complications. I've been burned too many times trying to manage pain in the recovery room in the presence of Suboxone. So, I will try to keep this brief to help those having surgery:

1. Between the buprenorphine doses of 16-32 mg, 80-90% of the opioid receptors are occupied. At 5 mg per day, roughly 50% of receptors are occupied by buprenorphine. So, other receptors are available to manage pain. That being said, it is always best to stop the Suboxone 7 days prior to surgery if possible or to minimize the dose to less than 16 mg. I took care of a c-section patient on buprenorphine 32 mg per day and it was not pretty. No opioid worked for her whole hospitalization. I have taken care of a similar patient on buprenorphine 8 mg per day and had minimal issues. So, the dose and consideration of available receptors matters.

2. When possible, request additional regional anesthesia for pain control. Regional anesthesia is the use of local anesthetics (lidocaine, ropivacaine, bupivacaine, etc.) to numb regions of the body (limbs, abdomen, etc.) for hours. This is the best pain relief you can get. As an example, for a simple knee surgery you should request a femoral nerve block. A good femoral nerve block results in up to 36 hours of numbness. No ortho case is too simple for regional anesthesia in Suboxone patients.

3. Request a 50 mg IM injection of concentrated ketamine. This typically reduces opioid needs in half and can make post op pain more manageable.

4. Request peri-operative gabapentin or pregabalin for peri-operative pain control. If I were to assign a number to it, I would say these medications contribute to a 30% pain reduction.

5. Ice may be the best form of pain control.

6. Request a dose of ketorolac (Toradol). It is an NSAID bu so many patients swear by it for post operative pain relief

7. For labor epidurals, the typical mixture used will work. However, an additional 0.3 mg buprenorphine into the epidural infusion bag works like magic. Patient typically remain pain free throughout labor.

8. For c-sections, ask for an additional transverse abdominis plane block (TAP block). This renders the incision pain-free. This can be done for any abdominal surgery. My c section spinal mixture includes 1 mg morphine, 0.3 mg epinephrine in addition to my usual bupivacaine. My colleagues are too afraid of using that morphine dose (5 times the usual dose) or the epinephrine dose. Most suboxone patients are very tolerant to spinal morphine. The epinephrine triples how long the morphine last giving up to 3 days of pain relief.

9. For infiltrating certain wounds (hernia, abdominal, etc.) request Exparel. This is a long acting local anesthetic that is very expensive, but may provide up to 3 days of pain relief.

I typically stop Suboxone 7 days prior to surgery, I place patients on an opioid they've never abused or one that doesn't cause them euphoria. The purpose of the opioid is to prevent withdrawal. Post op, I increase the dose of the opioid, then restart Suboxone when surgical pain subsides. For high risk patients, I continue a minimum of 8 mg of Suboxone and add a smaller dose of opioids. For some reason, the Suboxone prevents the euphoria of the additional opioid.

There is so much more to add, but I said I would be brief.

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Another anesthesiologist's perspective

Post by suboxdoc » Wed Nov 06, 2019 9:12 am

Not sure if you're aware, but I'm Boarded in anesthesia as well. I trained at Penn and worked in the OR for about 13 years.

I do not agree, at all, with stopping buprenorphine in advance of surgery. As you know, buprenorphine is not an issue in the OR. It is easy to overcome the mu-receptor blocking effects of buprenorphine using fentanyl - and frankly, opioids are not vital to ANY anesthetic (they smooth out the vitals, but a creative anesthesiologist can use beta blockers or other drugs to do much of the same). Local and regional techniques are helpful and should be used if the patient agrees with the plan. TOO OFTEN, patients are forced to accept a plan by an anesthesiologist who is stuck in his/her OWN plan. I have received many emails over the years from patients who had an anesthesiologist who forced a regional technique, or cancelled the surgery 'because you're on Suboxone'.

I've written quite a bit over the years about treating acute or post-surgical pain while on buprenorphine. It isn't that difficult to do - but it is difficult to get doctors to do it. It all comes down to mu-receptor competition. A higher dose of oxycodone will out-compete buprenorphine. As you mentioned, patients receiving high doses of oxycodone, while on buprenorphine, do not feel 'high'. I presented that fact at an ASAM conference, about 6-7 years ago.
Buprenorphine also prevents tolerance escalation from opioid agonists - and I've used it as a tool for that purpose in severe chronic pain cases https://www.slideshare.net/jeffreyjunig ... m_search=2.

I'll hear about failures like your C-section patient now and then when they find this forum and contact me. The block by buprenorphine is COMPETITIVE. It can ALWAYS be defeated by enough agonist. But here is what happens... the patient is given a certain amount of morphine. When the dose gets above a certain number, the doctor freaks out and changes to a different opioid. When they get to a dose of, say, fentanyl that they consider 'too high', they change to Dilaudid and do the same. They never get to a therapeutic effect of ANY opioid because they focus on the number and think it is 'too high' - even if the respiratory rate is still in the 20's! The solution is to use ONE opioid - preferably a lipid-soluble one - and push the dose as high as necessary. Your C-section patient should have received fentanyl, ideally a PCA, with a dose that works - no matter the number. Put her in a monitored bed, and crank it up. At a high-enough dose, her pain will be controlled. Respiratory depression and analgesia occur through the same receptor (!), so what's the fear? Too many times, a non-thinking doc will say 'we can't go any higher' and change drugs, or add ketamine (which is very nauseating to some people). Just push the agonist, and watch respiratory rate. The half-life of buprenorphine is longer than the elimination half-life of fentanyl, so there is no risk of the fentanyl 'accumulating' and causing harm.

I typically take over post-surgical pain control from surgeons, so I've treated hundreds of people, over the years, with combinations of agonists and buprenorphine. It typically takes 15 mg of oxycodone every 3-4 hours for good analgesia, but sometimes it takes more. People having major shoulder operations need the most narcotic, and I've used 30 mg of oxycodone in some cases. Patients on buprenorphine can often control their agonist use to their own surprise. And when the agonist is no-longer needed, they simply stop it and continue the buprenorphine.

If you stop buprenorphine in advance of surgery, the patient will come to the OR dehydrated, depressed, anxious, and miserable. That's making the huge assumption that patients will actually follow such an instruction. People on buprenorphine do NOT like to stop taking the medication, because they live in intense fear of withdrawal. I regularly hear patients say that they aren't going to tell the anesthesiologist that they take buprenorphine, or pretend they stopped it. I always recommend being honest for the sake of safety- but I understand where they come from. The comment of yours I would be most critical of is the suggestion to stop buprenorphine for 7 days - as if that's an optional thing for these patients. If you had major surgery coming up, would you like to have diarrhea, depression, nausea, fatigue, and insomnia for the week before surgery? AVOIDING those symptoms should be a priority - and it isn't that hard to avoid by a caring surgical team.

Stopping buprenorphine creates so many problems beyond discomfort. The person still has a high opioid tolerance, and anesthesiologists usually ignore that tolerance in the OR, thinking that they're 'normal' because they stopped buprenorphine. Patients in that position need a couple hundreds micrograms of fentanyl just to 'break even', and in the PACU they need about 40 mg IM morphine just to treat their withdrawal - before ANY analgesia. And in the subsequent days, those patients alternate between withdrawal symptoms (with magnified pain) and periods of analgesia and relief from withdrawal - a precarious position for people with impaired control over opioids. Re-inducing is difficult; patients need to be in withdrawal, and in pain, for 24 hours before going back on buprenorphine. I wouldn't expect my dog to go through that much misery, and it shouldn't be demanded of patients on buprenorphine - when other options are available to them.

This is what I give to patients having surgery, to share with their surgeon and anesthesiologist: surgery.pdf

Thanks for sharing your opinion, but please consider what you're asking people to do by stopping buprenorphine. Most of your patients CAN'T do that, and none of your patients WANT to do that. Instead, encourage surgeons to do what they learned in med school and residency - i.e. ignore the number of milligrams of the agonist and treat the patient (who is on a competitive opioid blocker).

In the OR, treat the respiratory rate. If RR is over 20, your patient will wake up in pain. Add more fentanyl. In the OR, use a loading dose of hydromorphone and stick with that drug (morphine's histamine release gets in the way of high IV doses of that medication). Once doctors ignore the number of milligrams and treat the patient, it isn't that difficult to provide post-op analgesia AND avoid a week of withdrawal symptoms.

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Re: An Anesthesiologist's Perspective

Post by Grace » Thu Nov 07, 2019 6:34 am

Hi there! I am new to this forum but a LONG time Suboxone patient. I take 0.5 mg per day. 40 yo female and I’ve been using a low dose of Suboxone through a doctor for 10 years. I started it after being addicted to pain pills for years from back pain. We stayed at a low level cause it keeps me honest, helps some with pain, and a long slow taper is what my original Suboxone doctor recommended. Original Suboxone doctor was great and knew so much about it. He was an ER doctor, general surgeon and had a urgent care practice when I began treatment with him. (He moved out of state 4 years ago and I’ve been having it prescribed by a psychiatrist since).

I am having surgery on December 12. Same day surgery for an anal fistula. This is not an elective surgery. The doctor performing the surgery has concerns about me being on Suboxone and asked me to talk to my Suboxone doctor about switching to Subutex. My Suboxone doctor - a psychiatrist - had no issue with me switching and prescribed the Subutex which I will switch to on Saturday. (It’s a lot harder to break up the 2 mg Subutex tablet than it is to cut up a 2 mg Suboxone film, but I’ll do my best).

Neither the rectal surgeon nor my psychiatrist really know a lot about Subutex in terms of surgery and I am extremely anxious about it.

This is a same-day surgery and will not require hospitalization. We are doing it in a ‘surgery center’ and I will be under general anesthesia. The Surgeon says it’s a pretty basic surgery and from what she can see in examination, the fistula is superficial and should not be overly complicated to correct.

My biggest fear is during the surgery. The rectal surgeon kept talking about Suboxone blocking the anesthesia and having issues with that. I do not want to be awake and suffering during this surgery. Afterward- specifically regarding post operation pain - I can deal with that as it comes. She said she thinks the Subutex and Advil should be enough to deal with any post surgery pain. So fine - hoping that’s accurate.

But I’m real scared of being on that table and being awake and/or feeling this surgery.

At this low a dose of Subutex (0.5 MG) will the anesthesia work to keep me under during surgery?

The rectal surgeon is highly rated for what she does, but she does seem out of her element in regards to my case and being on Suboxone/now Subutex.

Should I call the surgery center and try to talk to the anesthesiologists there? I’m just very concerned. And my psychiatrist really doesn’t know what to say. They both say the other should know.

Any information would be very much appreciated.

Have a blessed day.

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Re: An Anesthesiologist's Perspective

Post by suboxdoc » Thu Nov 07, 2019 11:23 am

Hi! Hopefully I will be able to ease some of those fears.

First, Suboxone vs. Subutex isn't an issue (Subutex was an old brand name that was removed from the market 8-10 years ago; now instead we have 5 generic manufacturers of plain buprenorphine). The naloxone in Suboxone is barely absorbed - about 3% makes it into your circulation - and has a very short half-life. Any naloxone you absorb will be gone from your body within an hour or so. All of the 'blocking' problems from Suboxone come from the buprenorphine, not from the naloxone.

Recall during general anesthesia would not be caused by Suboxone, and if it ever happens to anyone here, please contact me and let me participate in your malpractice suit. Buprenorphine blocks only opioids. It has no effect on volatile anesthetics, benzos, propofol, or other non-opioids. General anesthesia usually consists of a balance of medications these days, each used for certain purposes. Opioids reduce the body's response to pain during surgery, and help the patient wake without too much pain. Narcotic-based anesthesia techniques are notorious for allowing recall (for example the older, high-dose fentanyl anesthetics used for heart surgery). No competent anesthesiologist would use a narcotic-based anesthetic for a patient on buprenorphine, or for a day-surgery patient.

Other components of an anesthetic include a paralytic agent (like norcuronium) and an anti-recall agent (either a gas combination like nitrous/sevoflurane, or an infusion of white stuff called 'propofol'). None of these medications are impacted by buprenorphine. Recall is a major source of malpractice claims, but is very unlikely in your case - and if it occurred, it would not be related to your Suboxone or Subutex).

The main issue of concern is post-op pain. As I wrote yesterday, pain is treatable in patients on Suboxone or buprenorphine. But some doctors haven't learned enough about buprenorphine to know how to treat post-op pain. That is very frustrating for me, and you probably saw my frustration in my last post. It is NOT that difficult, and doctors routinely have to learn about new meds. Buprenorphine has been in common use in the US since 2003 - 16 years ago!!

The buprenorphine you usually take will NOT provide pain relief. You are fully tolerant to that dose. You MIGHT get pain relief if you increase your dose of buprenorphine, depending on how close your blood level is to the 'ceiling effect'. If you are AT the ceiling effect, then more buprenorphine will do nothing for your pain.

If you have severe pain and need opioid pain relief, you should keep taking your usual dose of buprenorphine and add oxycodone if you are taking pills (fentanyl IV if you're in the recovery room). It will take more oxycodone than usual to treat your pain. As I wrote before, I usually give 15 mg of oxycodone every 3-4 hours for post-op pain, and I've sometimes had to give more than that.

If your doc wants to speak with me about post-op pain on buprenorphine, I would be happy to have the discussion. Send me an instant message here. Good luck!

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Re: An Anesthesiologist's Perspective

Post by Grace » Fri Nov 08, 2019 1:16 pm

Thank you so much for your reply! I feel a lot more at ease, at least concerning the anesthesia. I will definitely discuss the post op pain situation with my doctor well in advance of the surgery. I truly appreciate your offer to talk to my doctor and may take you up on it depending on how our conversation goes.

Thanks again!

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Re: An Anesthesiologist's Perspective

Post by PremierHealth » Sun Nov 10, 2019 3:49 pm

I trained at Johns Hopkins and have worked in the OR for 19 years. I continue to practice addiction medicine, anesthesiology and pain management. There is a good chance that my preceptor was your chairman at Penn. That said, my opinion on peri-operative buprenorphine changed with the experience I had with the C-section patient. I've been treating patients with buprenorphine since 1999 and have always taken the perspective that due to the competitive nature of it, I could overcome the opioid receptor affinity with higher doses or potencies of opioids. This belief failed miserably in that c-section patient and I began noticing similar issues in a few other patients. But just to demonstrate what we (the patient's anesthesiologist and I) went through:

Spinal 1.6 ml 0.75% bupivacaine with 0.3 mg duramorph + 25 mcg fentanyl. Patient started feeling pain during the closing portion of the surgery, then proceeded with uncontrollable pain in the PACU. 200 mcg fentanyl, 30 mg ketorolac, 1 gram Ofirmev and 4 mg dilaudid IV provided no help. The anesthesiologist called me and I convinced him to place a 2 mg duramorph spinal and a TAP block. The TAP block helped the incisional pain but no improvement with the internal pain. She was given clonidine and labetalol to control the hypertension and tachycardia (she was not hypertensive pre-op and did not have pre-eclampsia). Post op, she was prescribed 120 mg of oral oxycodone per day to no avail. Finally on day 3 or 4 she began refusing the oxycodone and just wanted to go home. But the pain continued to be severe. At that time, she was sober for several years and had been compliant with all aspects of treatment so I had every reason to believe her. Now, this young lady had 3 or 4 more surgical procedures since that time but with a 7 day discontinuation of her buprenorphine prior to surgery. We've avoided this experience for her. In fact, her pain has been well controlled for the dental, gyn and orthopedic surgeries she had.

I've had similar situations with patients on high dose of buprenorphine typically 24 mg and above. I've never cancelled a case due to the presence of buprenorphine; that would be a career ending move in the private practice environment that I am in. Also, would never fail to obtain informed consent for regional anesthesia, again, a career ending decision in the area of the country where I practice. However, I find it important that each patient presenting to surgery while on buprenorphine (especially high dose) be informed of the potential interaction of buprenorphine, the peri-operative opioids, and the potential difficulty in managing the post op pain. All options should be on the table including multimodal analgesia. That way there are no surprises or disappointments. Low dose buprenorphine should not be a problem, but for someone on 16 mg or above contemplating a moderately painful surgery should have a discussion with an anesthesiologist so everyone in that practice is prepared and on the same page. I just presented the options I give my patients so that their pain will be kept to a minimum post op.

I agree, you shouldn't stop buprenorphine pre-op and not provide some form of replacement or treatment for withdrawal. Lower dosages of buprenorphine shouldn't be a problem and definitely is fine to continue for surgery of less than moderate post op pain. But for my recent patient on 16 mg buprenorphine about to have a 5 level anterior/posterior lumbar spine fusion, I took him off and replaced it with dilaudid pre-op. My other patient on 16 mg buprenorphine about to have a knee arthroscopy, I kept him on his buprenorphine without an issue.

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Re: An Anesthesiologist's Perspective

Post by suboxdoc » Mon Nov 11, 2019 11:19 am

I was at Penn in the 1980's under (sp?) Longnekker, Those were the golden years, with Frank Murphy and the younger Eckenhoff managing the OB service.

200 micrograms of fentanyl doesn't 'add' with 4 mg of Dilaudid. That's my point - that docs seem to think that a couple of subtherapeutic doses add up to one therapeutic dose. They don't. Neither dose is very large; 4 mg of Dilaudid is as potent as only 10 mg of oxycodone, and would barely cut it in a non-opioid-tolerant person. And 200 mics of fentanyl is not that large to a tolerant patient.

Competition at the receptor depends on the comparative level of each ligand (my PhD is in neurochem- readers can watch us compare credentials!). If a receptor had a perspective, the perspective of the mu receptor is that there is buprenorphine, and low levels of dozens of circulating molecules with lower affinity. The presence of a low amount of fentanyl does NOTHING to aid binding by hydromorphone.

The key information missing on this patient - what was her respiratory rate? If it was above 16-20, SHE NEEDS MORE NARCOTIC. If it is below that, one would start to wonder if she is acting out to some extent. Analgesia and respiratory depression are two sides of the same coin - mediated by the same receptor.

She isn't a day-surgery patient, so send her to a monitored bed, and give her another 4 mg of IV hydromorphone. Wait 15 minutes and repeat. Then repeat again until respiratory rate is below 16-20. Don't give any other respiratory depressant, like benzos, that only limit your ability to give opioids. Giver her her usual dose of buprenorphine each day so that she doesn't experience withdrawal between doses, once an adequate blood level of hydromorphone has been reached. You could lower the dose of buprenorphine, but there is no evidence (yet) showing better competition by agonists at lower doses of buprenorphine. Logic says that a lower dose would help.

My first point is that the numerical dose of agonist is meaningless. You certainly learned somewhere along the line to dose to effect-- something very easy to do with opioids in a hospital environment. Why add ketamine when she only received 4 mg of hydromorphone and 4 cc of fentanyl?! On buprenorphine, her tolerance is equal to about 60 mg oxycodone per day - i.e. about 24 mg of hydromorphone per day. That's just to break even!

My second point is one I've learned from my buprenorphine patients: telling a patient to stop buprenorphine for 7 days is a very big, insensitive thing to do. Frankly, most OBs I consult with freak out over 24 hours of opioid withdrawal in their pregnant patients. Telling a near-term pregnant woman to stop buprenorphine for 7 days can easily trigger labor. How would you 'manage withdrawal' in such a patient? With opioids? Really? You're going to give a term-pregnant woman with a history of addiction 40-60 mg of oxycodone per day? That's against the law, of course.... but it also invites a huge amount of risk, and makes her life much more miserable and complicated. Any other effort to 'manage withdrawal' has even worse associated problems. Clonidine? Benzos? Hydroxyzine?

You can avoid ALL of that polypharmacy by just sticking with her buprenorphine.

I used to argue this with docs when the NIH consensus paper came out on managing acute and surgical pain in buprenorphine patients. They listed three options - increasing buprenorphine, stopping buprenorphine in advance and using agonists, or the approach I described. Since then things have clearly changed in the literature, recognizing the problems (and misery) created by stopping buprenorphine - when there is no need to stop it.

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Re: An Anesthesiologist's Perspective

Post by Amy-Work In Progress » Thu Nov 21, 2019 7:38 pm

Wow! Fascinating discussion!

It seems that a simple shift in perspective (plus all of the information/knowledge required to be a board certified anesthesiologist) is all that is required to successfully treat the pain of a buprenorphine patient. What strikes me is that the addition of more subtherapeutic opioid analgesics does little to tackle the pain of that patient. One might think that piling on more opioids would raise the overall analgesic effect, but apparently it takes just one opioid at a high enough level to do that. Now, to educate the rest of the medical field!!

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Re: An Anesthesiologist's Perspective

Post by jennjenn » Sun Dec 01, 2019 10:35 am

I love reading this stuff! All the while I am sitting here thinking that in my area I bet you anything that a suboxone patient would suffer because the anesthesiologists around here could care less about if an addict's pain is covered. I 100% believe that the medical staff around here would look at it like we ruined our chance of having any pain controlled when we started abusing opiates. Nobody would believe how poorly we are treated in my area. Judgement is extreme!
Jennifer

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Re: An Anesthesiologist's Perspective

Post by TeeJay » Thu Dec 05, 2019 11:42 pm

PremierHealth wrote:
Tue Nov 05, 2019 12:52 pm
3. Request a 50 mg IM injection of concentrated ketamine. This typically reduces opioid needs in half and can make post op pain more manageable.
:D

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Re: An Anesthesiologist's Perspective

Post by Subsssavedmylife » Wed Jul 01, 2020 8:38 pm

I had emergency surgery 3 weeks ago and I couldn’t get them to read any of this. My pain wasn’t under control at any point. I normally take one 8mg/2mg suboxone (dosed at 1/4 of the strip every 6 hours). I vomited, hyperventilated and passed out several times. A nurse fell on me pulling on my catheter and they failed to bring medication as requested by my doctor. I’ve never been in that much pain. I begged them to send me home since they were failing to help me.
I pray that this information gets out to other facilities so they can properly take care of suboxone patients. I can’t imagine going through that pain again. 😭

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Re: An Anesthesiologist's Perspective

Post by rule62 » Fri Jul 03, 2020 7:49 pm

I like your user name. So appropriate for this forum. Yes, my doctor (surgeon) and many others don't like reading other doctors opinions. When i tried to get my very talented surgeon to either read the papers or to me breaking it down he abruptly said "I don't want to discuss it". My guess was he just viewed me as an addict because of my use of Suboxone. Worst pain I ever had. My wife wanted (and still wants) to sue him for unnecessary and untreated pain. The best he did was a 10 mg Norco after a very invasive surgery on my tongue.

All we can do it try and hope for the medical world to catch up. It's amazing how much more informed we patients are vs the entire medical field. I've had nurses ask what buprenorphine was. How can we get treated properly if they don't even know what the drug is?

Sorry, I'm beating a dead horse. Thanks for the post. We need to save this one for sure. The information is like gold.
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