I recently resumed writing for the expert forum on addiction at MedHelp.Org. One result of writing for MedHelp is that I receive a number of e-mails from people with questions about specific issues related to buprenorphine. The most common questions are from people on buprenorphine undergoing surgery, asking about the safety of anesthesia and about postoperative pain control.
There are very significant problems with medical coverage for patients on buprenorphine undergoing surgery. Patients on buprenorphine will occasionally need surgery, and in such cases there are often no doctors willing and/or competent to manage postoperative pain. Psychiatrists, frankly, have little knowledge or experience in this area. Before psychiatry residency, medical school graduates generally complete a medical internship that provides little or no training in critical care or surgery. Making matters even worse, the medical students who go into psychiatry tend to be those who have the least interest in the surgical specialties.
And then there are surgeons. Where psychiatrists lack courage to provide effective pain relief for addicts, surgeons simply lack interest or concern. Surgeons enjoy being in the operating room, cutting things apart and sewing things together. The last thing they want to do is have a heart-to-heart talk about someone’s addiction to pain pills. To a surgeon’s way of thinking, addiction doesn’t even exist. You can’t cut it off or sew it on, so why even talk about it?
Hopefully, those of you who take buprenorphine will slip this article under the door of your psychiatrist to drop a hit about this problem. I cannot provide medical recommendations for people who I do not know, but I will at least provide some general information so that readers of my blog will know when they are being fed a line of nonsense.
Speaking of nonsense, the silliest and most potentially harmful advice that I hear about in e-mails is that buprenorphine will cover a person’s postoperative pain; that the person should simply take his/her normal dose of Suboxone and everything will be fine. Nonsense! People taking buprenorphine quickly become tolerant to the pain-relieving properties of buprenorphine, and therefore will not get adequate pain relief from buprenorphine for anything but the most minor surgical procedures. Buprenorphine has complex actions at opioid receptors, including partial agonism at mu receptors and mixed effects at kappa opioid receptors. The actions at kappa receptors are less subject to tolerance and provide some long-term effects on mood and analgesia, but these effects are not even close to what is required to cover postoperative pain.
There are several articles that have been published that describe various approaches for treating postoperative pain in patients on buprenorphine. I cannot post the articles here because of copyrights, but the general recommendation in the literature for treating post-op pain is to reduce the daily dose of buprenorphine starting several days before the surgery, and to use potent opioid agonists in addition to buprenorphine. Another option is to stop buprenorphine completely before surgery. But buprenorphine has a long half-life, and must be stopped for a week or more in order to significantly lower the level of buprenorphine in the body.
It is important to understand that there are two things that get in the way of pain relief in patients on buprenorphine; the antagonist actions of buprenorphine at the mu receptor, and the patient’s high tolerance to opioid agonists. Even if buprenorphine is stopped a week or two in advance of surgery, the person still has a high tolerance to opioids, and still requires significant doses of opioid agonists for adequate post-operative pain control. And if buprenorphine is stopped completely, the person must go through a period of withdrawal before eventually restarting buprenorphine in order to avoid precipitated withdrawal.
I have found it easiest to keep the person on a small dose of buprenorphine, perhaps 4 mg per day, throughout the entire operative period, until postoperative opioids are no longer needed. I’ve had good success treating post-operative pain with high doses of oxycodone while continuing buprenorphine, even after major surgeries. Interestingly, patients report good pain relief but the complete absence of the euphoria that they used to get from opioids. At the point after surgery when opioid agonists are no longer necessary, patients simply stop the agonists and resume their full dose of buprenorphine.
Whether or not buprenorphine is discontinued, high doses of opioid agonists are required to provide adequate pain relief for major surgery. An oxycodone equivalence of about 60 mg per day is required just to ‘break even’ with the tolerance of a typical person on buprenorphine maintenance. You can understand, then, why psychiatrists are wary of treating postoperative pain. Such high doses of oxycodone could easily cause fatal overdose in patients not taking buprenorphine. I am board certified in anesthesiology, but even I get nervous in such situations. But what is the alternative? I have had patients who required coronary bypass, hysterectomy, and total knee replacement, as well as minor surgeries. Dental work in particular is quite common in patients with a history of addiction. Should people on buprenorphine simply go without the necessary procedures that other people are allowed to have?
If psychiatrists or surgeons are unwilling to provide adequate postoperative analgesia for patients to take as outpatients, patients should allowed to stay in the hospital, even the intensive care unit, if that is what it takes for the doctor to feel safe providing adequate analgesia. Surgeons should provide adequate care, even if they have to fill out paperwork and battle insurers to obtain the necessary coverage for hospitalization. They would do the same for patients with brittle diabetes who need close monitoring following surgery. Opioid addicts are people too!
As for general anesthesia, buprenorphine does not pose significant problems, provided that the anesthesiologist is aware that the patient takes buprenorphine and has a high opioid tolerance. Opioids are often used during anesthesia to blunt changes in blood pressure and heart rate, and larger doses of opioids would be required for people taking buprenorphine. The amnesia component of an anesthetic is generally provided by medications not blocked by buprenorphine, such as anesthetic vapors or benzodiazepines.
Another reason that anesthesiologists must be made aware if a patient is taking buprenorphine is so that sufficient opioids are ‘on board’ when the patient awakes. As patients emerge from anesthesia, anesthesiologists often use respiratory rate to gauge whether sufficient doses of narcotics have been provided to cover postoperative pain. Without the knowledge that a patient is on buprenorphine, the anesthesiologist may be confused by the patient’s lack of response to narcotics, causing the anesthesiologist to give too little pain medication—meaning that the patient will awake with considerable pain.
Medications with combined actions (such as tramadol and the newer agent Nucynta) or of little value for post-operative pain control. These medications have actions at mu opioid receptors that are blocked by, and cross-tolerant with, buprenorphine– completely nullifying that component of their action. The other component of their action is through effects on serotonin or norepinephrine pathways, and these actions are insignificant for post-surgical pain. Because of mu receptor tolerance, Nucynta essentially becomes as useful for treating post-op pain as Cymbalta— i.e. worthless!
I must stress that everything I have written here is intended to serve as a basis for discussion between patients and their doctors. Every case has unique variables that must be taken into account, and so my comments must not be taken as medical recommendations or advice. Taking high doses of opioid agonists can be dangerous, particularly in combination with other respiratory depressants.
One final comment… I recently received letters from two different health insurers about ‘buprenorphine policies’ citing situations where Suboxone would not be covered. These situations have included cases where patients are prescribed opioid agonists. I want to point out that there are times when patients on buprenorphine require surgery, and every patient undergoing surgery deserves adequate pain control. There are also patients on buprenorphine maintenance who have chronic pain; pain that in some cases justifies the relief afforded by opioid agonists. I hope that those with the power to influence policy, including Reckitt-Benckiser, the American Society for Addiction Medicine, NIDA, and SAMHSA, will direct attention to this important gap in medical coverage.