post op pain management for Suboxone patient

PCA= Patient Controlled Analgesia. The "press the button for a bolus" machine. 

gtrplayer

 The only post op analgesia I have ever used in Suboxone patients is further Buprenorphine therapy (usually a PCA loaded with Buprenex). If the patient was off Bupe long enough that it caused no problems for anesthesia (Buprenorphine precipitated opioid antagonism / precipitated withdrawal of OR opioid anesthesia - as Buprenorphine will precipitate withdrawal when combined with a full opioid agonist), then you obviously have to chose between allowing a full opioid agonist to be given to an addict (I wouldn't) or restarting Suboxone. The PT will obviously need a strong analgesic (probably narcotic) and Suboxone *is* effective for post op pain.

 If it were me I would give (script for) a single dose of Subutex (just to be safe since patient has h/o abuse and may inject if not administered in office) for the day, and Suboxone for the weekend, then re-evaluate Monday (or script for a longer take home dose of Suboxone, based on your judgement of PT Hx). Instruct to dose with Subutex no earlier than 4-6 hours following last full agonist dose. Also, consider Subutex 2mg as the starting dose immediately following the full opioid agonist (to lessen the likelyhood of precipitated withdrawal), then increase to 4mg or 8mg 12 hours later (you could give Subutex 4mg, then script for Suboxone 4mg Bid - 8mg BiD over the weekend). In my experience, BiD dosing of Suboxone works better when being used as an analgesic. An 8mg Bid dose would put the QDay dose at 16mg which is usually the maximum dose that addicts reach during Suboxone therapy and certainly enough for analgesia. Obviously the point of getting back on the Buprenorphine is to prevent relapse from the use of full opioid agonists.

 Bottom line - Buprenorphine 2mg at 4-6 hours post full agonist should minimize discomfort by displacing most of the full opioid agonist in a gentle fasion as it is being eliminated anyway, and 6-12 hours later a full dose of Suboxone 4mg-8mg (probably 8mg) can be administered without significantly worsening any precipitated withdrawal. Continue with BiD dosing of Suboxone at appropriate levels, remaining aware both of required analgesia and risk of relapse. Once analgesia is no longer a concern, revert to standard Suboxone opioid dependence protocol.

Just my 2 cents...

/Xtrasystole - BS.Bio, MS Anesthesiology, Pharm/M.D.

Always check with a physician/pharmacist licensed where you live before taking medication. My license does not extend past the state of my practice.

You said that the normal dosing for suboxone maintanence is 8mg BID (16mg per day) however the three people that i ever knew who had a suboxone script were perscribed 8mg TID not BID. The people I knew didn't always take the third dose but they were still perscribed TID. So although the "usual max" is 16mg per day this is not always the case.

 I said a usual dosing for Suboxone (in my experience) is BiD in patients on *pain management protocol* - not opioid dependence protocol. Of course, this is regarding off label use, so there isn't really an established protocol for pain management with Suboxone. Either way, a BiD dosing schedule should be sufficient for post op analgesia - Buprenorphine is an extremely long acting opioid, sometimes administered on an alternate daily schedule (once every 48 hours) due to its long half life.

 I am thrilled to hear that the Bupe had the desired effect. I have no doubt there is probably some residual antagonism of the Dilaudid as you mentioned, but that should be negligible compared to remaining unmedicated, or the risk of using a full agonist like oxycodone in someone with SHx of dependence. Congratulations on a case well handled. The Suboxone should continue to remain effective for analgesia as long as necessary, so you should be set regarding any further treatment and continued Suboxone therapy...

/Xtrasystole - BS.Bio, MS Anesthesiology, Pharm/M.D.

Always check with a physician/pharmacist licensed where you live before taking medication. My license does not extend past the state of my practice.

xstrasytole

"An 8mg Bid dose would put the QDay dose at 16mg which is usually the maximum dose that addicts reach during Suboxone therapy"

That is a direct quote from your post so no you did not say it was for *pain management protocol* you said it was for addicts during suboxone therapy. Either way even the people I knew who are perscribed 8mg TID only felt the need to take it BID. I know you were just comparing the pain management dose to what you thought was the average max dose for suboxone maintanence but I was just trying to point out that in my experience the average max dose is 24mg per day or 8mg TID. I am not trying to start an argument here just trying to post my experience with the people I know on suboxone. 

Dr. Lois, not sure if this helps you or not. But as you know I am on Suboxone for pain management. I received three rounds of shots over the last three weeks, and each time I went for my shot, they gave me fentanyl and Versed IV with no problems. When I got home, I was able to resume my Suboxone when I needed it. Like you stated in an earlier post, the IV fentanyl doesn't last very long, so maybe that is why I had no problems. But, that is my two cents for what it is worth. I had no precipitated withdrawal. I actually had nothing bad whatsoever occur.

To be honest, I've kind of lost track of what the original question was so I just posted this in hopes it had some relevance. :) 

gtrplayer

mainepain- I do not understand why you wrote this post, were you explaining this to someone else? 

I'm a social worker, not a medical professional. All comments and thoughts are simply my opinion and experience.

for the record from Rickitt Benckiser "The recommended target dose of Suboxone is 16mg/day.  Clinical studies have shown that 16mg of Subutex or Suboxone is a clinically effective dose compared with placebo and indicate that doses as low as 12 mg may be effectiive in some patients.  The dosage of Suboxone should be adjusted in increments/decrements of 2mg of 4mg to a level that holds the patient in treatment and suppresses opioid withdrawal effects.  This is likely to be in the range of 4mg ot 24mg per day depending on the individual" 

The point is you are both correct to some extent as RB considers 16mg a moderate dose and 24mg a high dose.

Check with a licensed MD before you take any suggestions!

Usually when precipitated w/d occurs in buprenorphine patients, the full-agonist is in the system before the bup.  Buprenorphine has such a high affinity that even fentanyl cant dislodge it from the opiod-receptors (at least not plain fentanyl, some of the analogues easily could).

For the most part, a Suboxone patient who takes a full-agonist will just experience less effects (if any) from the full-agonist. 

 Yes, almost all medical practitioners script for off label use of Rx (and OTC) medication from time to time, and even quite frequently depending on their nature of practice (for instance, psychiatrists frequently prescribe off label, as do anesthesiologists in pain management). The whole point of having recognized off label uses is to allow physicians and other healthcare professionals to know other possibly advantageous therapeutic properties of medications. As Dr. Lois mentioned, Buprenorphine is available and indicated for pain management in several other regions/countries (notably europe) as a TD (transdermal) formulation, and has been used as a parenteral analgesic in the U.S. and elsewhere since the 1980s. Buprenorphine was in fact originally marketed as an analgesic in the 1980s (in the parenteral form - trade name Buprenex), not for opioid dependence. At the time, it showed fairly widespread use, especially in operative anesthesia/analgesia (for which I still advocate its use in certain circumstances). Not until 2002 was the SL formulation specifically approved for opioid dependence by the FDA and combined with Naloxone HCl to form Suboxone SL (and without Naloxone, Subutex SL).

Additionally, it is humorous to me to see the suggestion that a physician have personal experience with every (or even any significant portion of) medication they prescribe. If that were the case, we would all be on so many controlled substances that none of us would be able to justify maintaining our medical licenses, much less our DEA and state control licenses.

Pharm companies only invest in FDA approval of new indications when there is the potential for considerable financial gain through that indication. For instance, Metoprolol is a beta-blocker used to treat high blood pressure and a variety of other cardiovascular conditions. However, it is also used frequently off label for "performance anxiety" or "stage fright," especially among concert and symphonic musicians. Due to the fact that there is not a stacked market for those seeking treatment for stage fright, Metoprolol will probably never be formally approved for stage fright as an indication by the FDA.

 -Oh and just for the record, I *have* in fact used (and am currently on a stable dose of) Suboxone for chronic pain management. This is after unsatisfactory trials of Tramadol / Gabapentin, then Hydrocodone, then Oxycodone. Suboxone has in fact been as close to a magic bullet as I have found for my particular type of chronic pain. Most importantly, it is as effective as Oxycodone (Extended), but does not share the side effect profile which was proving to be costly to my career. For awhile I was popping Vicodin more often than House, MD (for those of you familiar), and to be honest, a doc high on Vicodin might be funny on TV (and from time to time was humorous to some people I knew), but in actuality, practicing medicine with potent short acting full opioid agonists pumping through you is not a good idea. It is very easy to go from physician / pain management patient to physician / opioid addict in no time at all with little to no warning...

/Xtrasystole - BS.Bio, MS Anesthesiology, Pharm/M.D.

Always check with a physician/pharmacist licensed where you live before taking medication. My license does not extend past the state of my practice.

"I really am not in a position to take all the medications I prescribe, but I must admit I am curious about trying 20mg of oxycodone to see what the big deal is some day!"

 Dr lois i noticed this comment in one of your posts, how would you go about doing something like that as a MD. Would you have one of your buddy MDs Rx you them, Would you Prescribe one of your patients 2 extra oxycontin 10mg tablets and say bring them back to me? How does that work? Just very curious BC I know that you cannot RX yourself a script but can you RX your husband or wife a script of say oxycodone 15mg tablets #10 just for a test run. I am really curoius to hear how it works...I once had a dr that told me that he tried every medication that he prescribed to his patients so he knew what to tell them to expect.... 

 Solo,

You are correct in some of the ideas you mentioned regarding dosing. In general, pain management patients do not require quite as high of a dose (of Buprenorphine) as would an opioid dependent patient (being treated as such). This is due to the fact that there is still considerable analgesic activity at lower doses (2mg QAM for instance). As far as Temgesic, mcg dosing is usually several times a day I think, although I don't have much experience with Temgesic dosing (for those of you who are unaware, Temgesic is the PO/SL formulation of Bupe which was intended for pain). I don't think Temgesic is used much any more (I have never dispensed or ordered it), probably due to the decline in Buprenex use, as Temgesic was used for non-parenteral Buprenorphine analgesia in patients who had previously been dosed with Buprenex (as one might during operative anesthesia). Either way, Temgesic tabs (0.2mg) have only a slightly lower bioavailability (80-95%) when administered correctly SL compared to Buprenex Inj 0.3 mg/ml (obviously 100% bioavailable). Inconsistent SL administration technique sometimes causes variations in bioavailability, however, which means that SL preparations can be as little as 5-10% available - or even less (if swallowed, not allowed to properly dissolve, etc...). Of course, one of the most important factors is how opioid naive the patient is, as you mentioned as well Solo. In dependent patients (the ones on Suboxone for addiction), there is usually quite high cross-tolerance, making them non-opioid naive. Pain patients, on the other hand, can be opioid naive, especially if they are introduced to opioid pain management through Buprenorphine as opposed to more classic first line opioids (those in CIV and CIII) including Propoxyphene, Hydrocodone, Codeine, and recently Tramadol (the usual suspects when considering opioid therapy for mild-moderate non-malignant pain).

/Xtrasystole - BS.Bio, MS Anesthesiology, Pharm/M.D.

Always check with a physician/pharmacist licensed where you live before taking medication. My license does not extend past the state of my practice.