What if someone on suboxone was put in the hospital for pain?

[Orchid_Suspiria]

What kind of opiate would they treat them with?What would be strong enough to override suboxones blocking agents?Swim suspects fentanyl,and perhaps benzodiazepines.

What exactly would they do?

[OhCasey]

I dont know if fentanyl is strong enough to override the blocking of opioids. They might just use suboxone since it can be used to treat pain both accute and chronic. I know it has a ceiling for euphoria but i dont know if that necessarily translates into a ceiling on pain relief.

[Orchid_Suspiria]

Fentanyl is extremely strong.Swim would hope if he went to the hospital he would have the right to a little euphoria.

[OhCasey]

I know that fentanyl is very strong but im almost certain that it doesnt break through the suboxone. I know that individuals on Fentanyl already who then take suboxone without going into withdrawals first experience withdrawals from the Bupe.

[biggpri]

SWIM was on a suboxone detox program and asked his doctor this very question. the doctor's reply was that they would either 1) use more suboxone, as it has analgesic properties or 2) use a large dose of a strong opiod to outweigh the bupenorphine

[Orchid_Suspiria]

Swim would hope for option 2 if he got put in the hospital.Swim is very certain it would be fentanyl.

[bman1]

Swib ask a freind who is prescribed Suboxone. Swib asked this question. Said peron pulled out a medical card in ones pocket. It was just like a medical allergy card. But stated they one one a certion opiate block and would need differemt treatment. If this person was sent to the ER. The can give said person something to make opiates work again. Said persons DR. stated if they go to the dentist or break something small just to go back to him and he would write a larger amount a subs to keep this person away from the opiates and dull pain.

[moda00]

Said person pulled out a medical card in ones pocket. It was just like a medical allergy card. But stated they one one a certian opiate block and would need different treatment. If this person was sent to the ER. The can give said person something to make opiates work again.

If they can give someone something to make opioids "work again" wouldn't that mean that could be utilized to reverse/minimize tolerance developing, is that what's implied? Or would that refer to something like buprenorphine and/or naloxone, ie. an antagonist or partial agonist/partial antagonist opioid drug, actually putting the person into withdrawal and "shutting down" or "plugging up" that receptor- but that wouldn't make sense either in this case because such things wouldn't allow any opioids to bind properly, and seemingly would not be an asset in an emergency situation. Would be interested to know any more about this.. not sure I understand the concept.. unless it's a really convoluted way of saying that he'd have to be treated differently because of the medication, by way of higher than usual doses of the painkillers..

I know methadone is not the same as suboxone, but the same concept applies not in the properties of the opioids, as I believe methadone is a full agonist, but due to tolerance that develops with long term opioid maintenance, and pain threshold is reduced. I have a letter from my doc stating this, and the one time I did have to be hospitalized they adhered to it, giving my my daily methadone for maintenance in the usual stable dose, and then giving me morphine in larger doses and more often (first injections, then sublingual) than protocol because of this.

But I don't see what medication would be used to render a partial agonist/partial antagonist opioid like buprenorphine ineffective while at the same time rendering full agonist opiates or semi-syth/synth opioids fully active?? I don't know much about pharmacology of opioids but this seems counter-intuitive, unless s/he means the dosing with bigger quantities of the narcotics used for pain in such a setting.. If anyone knows more about how this situation would be approached with suboxone I'd be interested in hearing more..

[Orchid_Suspiria]

I'm very curious how they would make opiates work again aswell?My only guess is somehow giving the person something like narcan to clear receptors.Otherwise I can't see any other viable way.

[Solinari]

I don't believe they can give a person on a blocking agent something to make them work again, i just can't see how it's possible.

As for the question, i doubt they are going to give someone a large dose of opioids to someone that has a history of addiction, i would guess it would be more buprenorphine and/or even some NSAIDs (i know it's an insult, but that's what they do).

[moda00]

I know proper pain management of those with opioid dependence is a really important issue, but I think it's moreso an issue with chronic pain or other conditions or on an outpatient basis. As long as it is supervised such as a hospital admission or ER visit or dental procedure, I think (and hope) it is usually managed well. As for acute pain, such as referenced in the OP, if one had to suddenly be hospitalized or needed surgery or something and pain was involved, I think the protocols are pretty evolved as far as acknowledging opioid maintained patients' needs.

One personally has an extensive history of opioid addiction, cocaine and other drug abuse, substance abuse treatment, and suicidality in her past, and with required paperwork and all she has always been treated very well with regard to pain management. Recently read an article (I think on DF actually?) about discrepancies in pain meds administered in the ER between racial groups.. so I think gender and race likely play into it, as do preconceived notions of addiction in this case, and a doctor's own preferences and history.

But if one is stable and on maintenance meds, and has information from their doctor on their medical needs with regard to pain management, it seems improper for them not to follow those guidelines (increased dose and shorter time intervals of administration should be standard in such case). I'm sure it happens, though, that people are discriminated against or improperly treated, and it sucks. But swim's own experience, she's thinking specifically of a kidney infection ER visit (dilaudid injections were given as needed- one of the most painful things she can remember experiencing) and an infection of the leg/foot called cellulitis, treated (along with iv antibiotics and acetominophen) with iv and sublingual morphine. And with dental procedures, she has done sedation with triazolam/diazepam, as well as nitrous, and has been prescribed a small dose of Vicodin or Percocet after procedures once or twice in recent years..

I think in such cases documentation is key, as is communication. If you are open about your needs and know what you need, and have documentation of this from your physician, they are much more likely to treat you appropriately imo.

But yes, I cannot see how that would work as a reversal agent would block all opioids from having effect.. But increasing the suboxone dose seems unlikely too imo, due to the ceiling.. but I don't know too much about this, will try to find more info..
See info in post below..

[OhCasey]

Originally Posted by Solinari

I don't believe they can give a person on a blocking agent something to make them work again, i just can't see how it's possible.

As for the question, i doubt they are going to give someone a large dose of opioids to someone that has a history of addiction, i would guess it would be more buprenorphine and/or even some NSAIDs (i know it's an insult, but that's what they do).

What would they do in cases of car accident victims who are way beyond NSAID's. No doc in his right mind would say your in an extreme amount of pain from a life threatening accident take some Ibuprofen Naproxen and Etodolac and call me in the morning.

[moda00]

Originally Posted by OhCasey

What would they do in cases of car accident victims who are way beyond NSAID's. No doc in his right mind would say your in an extreme amount of pain from a life threatening accident take some Ibuprofen Naproxen and Etodolac and call me in the morning.

I agree, the idea is a good one. But in practice (not a chem major) my understanding is that these block all opioids from binding- so what good would it do to block out the opioids currently attached from the receptors (which in the case of suboxone therapy, have no analgesic/pain-killing effect, but keep the patient out of withdrawal)?? I guess the effect is short lasting, I believe around 30-60 minutes for naloxone, but wouldn't they not only spend an hour not only in pain, but in horrible withdrawals? I am confused by this, but it is complicated I guess because buprenorphine is a mixed agonist/antagonist? So confused.. I think before this goes any further we need a source.. I'll be back.. Don't think my understanding of this is going to go any further, nor the discussion of it, until we understand the neurochemical factors and the protocol followed..
I will think myself in a circle if I don't find a source and stop speculating lol Be right back.
-----------------------
EDIT: Ok an answer! This is from an article in the Acute Pain management journal, doesn't go into the neurochemical specifics on buprenorphine activity itself, but is a first step and answers the question posed as far as what one would do in the case of a buprenorphine patient being hospitalized or requiring surgery. They state that for any maintenance opioid, buprenorphine or methadone, this is needed as a baseline to keep the SUD (substance use disorder) stabilized. So the concern is not changing the buprenorphine or reversing it, in most cases, according to this article, but giving enough opiate pain medication on top of the maintenance dose of suboxone/subutex to produce effective pain mangement. According to the article, appropriate pain management with higher doses of opioids than usual do not increase risk of relapse of a substance use disorder- but inappropriate pain management does. Will add this to the archive, and keep looking for info more specific to buprenorphine as opposed to just substance disorders in general, but this seems to be the basic answer as far as what I've read so far. Will also see if I can find more info on the studies of risk of relapse with opioid pain management versus mismanagement or withholding of pain meds. This does sound logical, and if this has been proven I think that is important for all doctors to know!!

Also, it is stated that the blocking effect of suboxone is due to it having both a strong affinity for the mu opioid receptors, as well as being a weak antagonist. So from the sources I've browsed thus far, morphine or fentanyl were referenced, but it seems the dose, rather than the specific opioid, is most important in this case.

This and other articles also discuss buprenorphine in the context of pain management for those not on opioid maintenance but with past history of SUD (substance use disorders). Since buprenorphine is a strong opioid, it is very effective for those who are not treated with any opioid drugs presently, and one other article discusses buprenorphine as a good option for chronic pain or outpatient prescriptions for those with a medical need for pain management but a treatment of substance dependence. Especially for those with former opioid addiction, buprenorphine/suboxone may be less likely to be abused because of the ceiling effect, but on the other hand, most pain management does not lead to relapse, so it seems to me a good option when effective, but for severe pain conditions or after tolerance develops, it could reach a point where they need to be able to use a drug that can be titrated upwards past that ceiling. I think it's a good option though, it just needs to be evaluated on a case by case basis.

Copy/paste:
The specific problems related to postoperative analgesia in patients with substance use disorders (SUD) concerning opioids, alcohol, benzodiazepines, barbiturates (Part I), cocaine, crack, amphetamines, amphetamine-like designer drugs (MDMA, ecstasy), LSD, and marijuana (Part II) are described. Whereas SUD with only one substance rarely occurs, the number of polysubstance abusers is increasing. Patients with SUD may have multiple organic diseases, impaired immune response psychiatric and behavioural abnormalities, and substance-induced disorders (intoxication, withdrawal, delerium, psychotic disorders), often associated with low compliance and craving behaviour.
The perioperative management should be focused on three problems: (1) on the prevention of physical withdrawal symptoms and stressful complications in patients with SUD using CNS-depressants, (2) on the symptomatic treatment of the predominant affective withdrawal symptoms in patients suffering from SUD with CNS-stimulants, and (3) on the effective pain treatment.
The analgesic therapy is often difficult and required for longer periods of time than in other patients. However, the principles of multimodal analgesia are as valid as in non-addicts. To be effective, systemic analgesia with paracetamol, NSAIDs and opioids has to be adapted as usual, but regional analgesia techniques should be preferred for postoperative pain relief.
Patients enrolled in preoperative maintenance programmes (methadone, buprenorphine) need their daily maintenance dosage as baseline. This baseline therapy does not, however, induce analgesia. Therefore, these patients need additional short-acting opioids which have to be administered at higher dosages than usual (which do not cause respiratory depression due to opioid tolerance). The additional opioid does not increase the risk of relapse into active SUD. On the other hand, regional analgesia in patients who are enrolled in a maintenance programme does not mean withdrawal prophylaxis. These patients have an excellent analgesia, but they need their previously used maintenance opioid to prevent withdrawal. Special considerations will have to be made in patients with naltrexone.
Recovering patients with a history of SUD have both an intensive fear of relapsing into the active SUD as well as fear of suffering from postoperative pain. These patients require an equally effective analgesia as other patients. Depending on the type of surgery and pain intensity they need atypical opioids (eg tramadol) or strong opioids (eg buprenorphine or morphine) as a part of balanced analgesia to the same degree as other patients. Withholding effective analgesic treatment can paradoxically lead to relapses in recovering patients. The common opinion of healthcare providers to withhold strong opioids from recovering patients with SUD is obsolete. However, in order to avoid psychotropic side effects the dosages of opioids, as well as the analgesic efficacy, should be monitored closely.

edit again, can only get the abstract so won't be adding this to the archive at this point, but to correctly cite it is: Bey, Tareg, & Jage, Jurgen. Postoperative analgesia in patients with substance use disorders: Part II Acute Pain. Volume 3, Issue 4, December 2000, Pages 20-28
Also interested in Part I of this article if anyone can access, but Science Direct only has this abstract listed via my school's proxy.

[OhCasey]

Well there you go. Nice job Moda, I looked for a lil bit and couldnt find any info on this so i gave up but you dug up more then enough to answer the question.

[JJx23]

I believe there is a drug out there that allows opiates to work again. If the case isn't that serious, wait a week and the narcotics will work again. But if you have a serious condition, that's different.

[moda00]

But the thing is, when someone transitions from dependence on opiates to a maintenance medication, their body is dependent on that. They couldn't just "wait a week" because that implies coming off the maintenance medication, which would not be recommended in such a case, for reasons of both recovery/addiction and also management of the pain or other symptoms related to the health condition. If there is such a medication that someone knows about, please find a source and post information explaining such. But until some more info comes to light, the concept does not make sense to me. Because if someone is maintained on suboxone, they need to stay on the suboxone- buprenorphine is an opioid, and it does work- it is simply a matter of high tolerance combined with the properties of that particular substance. So if such a drug existed, it would either reverse the effects of all opioids (which as I stated would be pointless except in case of overdose), or somehow reverse tolerance (which I think we would know about if this existed). I could be wrong, I am not a medical professional, but to me this just does not make sense, and seems to me to be a misunderstanding of opioid pharmacology.

[OhCasey]

Only thing i can think of that reduces tolerance is ibogaine and i dont think hospitals would use it in such a case. As far as just a drug that allows opiates to work again im pretty certain there isnt one.

[JJx23]

Well, I will have a look-see, but someone who I know had told me of a drug that reverses the effects. Obviously if a person is on a program where they need an Opiate Antagonist (naloxone), they would be trying to stay off of opiates, but there is always that case where they could get into an accident, or another form of pain that would require narcotics in a hospital. The person I talked to also told me that if you give someone a high enough dosage of narcotics, it would override the suboxone, so that's another possibility. These medications only stay in your system for so long, I mean after a week, and you should be through with them. The effects of other narcotics might not be at full effect after a week, but the buprenorphine would be out of your system. I know somebody who was off of Suboxone for a week and narcotics started to work again, so I suppose it depends on how much the person is taking, and for how long.

Another medical hint I had heard of was that a drug needed a counter-effect, or a drug that would reverse the effects of a drug, now this could be false, but it makes sense. Normally if you can think of it, it normally is out there. I definitely would like to know more about it.

Originally Posted by moda00

But the thing is, when someone transitions from dependence on opiates to a maintenance medication, their body is dependent on that. They couldn't just "wait a week" because that implies coming off the maintenance medication, which would not be recommended in such a case, for reasons of both recovery/addiction and also management of the pain or other symptoms related to the health condition. If there is such a medication that someone knows about, please find a source and post information explaining such. But until some more info comes to light, the concept does not make sense to me. Because if someone is maintained on suboxone, they need to stay on the suboxone- buprenorphine is an opioid, and it does work- it is simply a matter of high tolerance combined with the properties of that particular substance. So if such a drug existed, it would either reverse the effects of all opioids (which as I stated would be pointless except in case of overdose), or somehow reverse tolerance (which I think we would know about if this existed). I could be wrong, I am not a medical professional, but to me this just does not make sense, and seems to me to be a misunderstanding of opioid pharmacology.

[Solinari]

I can't see how it is possible. First off buprenorphine itself can only be partially reversed by something like naloxone which indicates it has higher affinity for the mu-receptor than naloxone which kicks any other opioid agonist out its receptor.

So if someone has buprenorphine or naloxone in their system there isn't anything else that can kick those drugs out the receptor and then leave that receptor free to be reoccupied by another opioid agonist immediately. I was thinking along the lines of an ultra short acting antagonist, but i am unsure what would happen to the other opioids drugs already in the system, maybe they would require immediate excretion and i don't think that is possible.

This is my basic understanding of how receptors work, but i can't say if it's completely accurate or not. I am pretty sure if there was something to reverse the effects of an antagonist like naloxone then we would know about it, sounds like something a drug worker would tell an addict to push them into taking an antagonist blocker.