Managing a Perioperative Patient on Suboxone

By Dr. Frank A. Kunkel and Katherine J. Kunkel

Introduction

Pain specialists who treat pain patients are frequently consulted about narcotic management issues. The generally accepted therapy for narcotic addiction involves cognitive-based therapy, such as Alcoholics Anonymous, Narcotics Anonymous, private meetings, etc. However, these patients experience extreme craving for narcotics, and medication use has evolved to help these patients pharmacologically while they strive to overcome their addiction.

One such drug used in the treatment of narcotic addiction is buprenorphine hydrochloride/naloxone hydrochloride dihydrate (Suboxone®), and it has profound implications for patients undergoing anesthesia and operative intervention. This medication is a sublingual tablet used to treat opiate addictions. The naloxone component of the tablet is not bioavailable sublingually. Buprenorphine is in the class of narcotic agonist/antagonists. The medicine works by binding to opiate receptors to provide a modest level of analgesia. However, Suboxone exhibits a 'peak ceiling effect' leveling its analgesic and side effect profile. Since buprenorphine has a very high affinity for the opiate receptor, other narcotics will have decreased receptor binding.

Traditional narcotics given at standard doses intraoperatively will have decreased analgesic effects on patients taking Suboxone. Unfortunately, many perioperative caregivers aren’t familiar with the treatment of narcotic-addiction patients. The key to appropriate treatment of acute pain (including perioperative) in the patient on Suboxone lies in educating medical providers on its pharmacology and supplying some general guidelines on its perioperative uses.

A Simple Explanation about Suboxone®

Imagine a ladder with ten steps. Step 0 is a patient who has no narcotics in the system. Step 10 is a patient on very high doses of narcotics. When patients with a narcotic addiction (sitting on Step 7 of the ladder) let their narcotic levels fall, they begin to experience withdrawal once they fall below Step 3. This withdrawal syndrome is profound and includes profuse sweating, cramps, diarrhea, agitation, and mood changes. Narcotic-addicted patients who fall below Step 3 of this ladder describe withdrawal symptoms as 'unbearable.'

Upon taking buprenorphine/naloxone, the patient achieves a balance between withdrawal syndrome and narcotic craving—essentially, the patient is on Step 3. If someone who is on Step 7 or higher of this ladder takes Suboxone, that person will instantly 'plummet' to Step 3. This rapid fall will induce the typical withdrawal syndrome. Therefore, patients, when first starting Suboxone, must wait until they begin to experience withdrawal, and then they can take Suboxone to raise them to Step 3.

Recall also that Suboxone has a very high affinity for the opiate receptor (think, Suboxone does not want to be pushed off of Step 3). Therefore, if an addiction patient takes hydrocodone/acetaminophen it will typically have little or no pharmacologic effect because Suboxone holds the patient at Step 3.

Can addiction patients on Suboxone overdose on narcotics? They certainly can if they take a high dose of a narcotic. Suboxone has a high affinity for the mu opiate receptor, but it can be displaced by high dose narcotics. The typical dose of Suboxone is between one and three tablets daily. The drug has a peak ceiling effect, meaning that if the patient takes more than three pills daily, he or she will not go higher on the ladder than Step 3. This ceiling effect is one of the great advantages of Suboxone, which deters its potential for abuse.

Suboxone will provide some analgesia (Step 3, remember), but its primary indication is for the treatment of narcotic addiction. If used inappropriately, such as dissolving and injecting it, the naloxone becomes bioavailable and the patient will go immediately to Step 0 on the ladder.

There is not a best practice model for the perioperative care of patients on Suboxone. Patient care should be individualized, but some general statements apply to most of these patients who often also have increased tolerance to narcotic medications. Careful titration of perioperative narcotics with appropriate monitoring for significant side effects remains the mainstay of treatment.

Pre-op Management

Stopping buprenorphine/naloxone two-to three-days before elective surgery enables the medication levels to fall and allows traditional opiates to be more effective. I have occasionally received calls from patients either in pain or, more frequently, beginning to experience withdrawal symptoms when they’ve stopped taking Suboxone in anticipation of elective surgery. In these cases, I try to see the patient immediately along with the support person. I’ll typically give the patient a prescription for short-acting narcotics (oxycodone and acetaminophen 5/325, # 10, one poq 4h prn) for a couple days, to be dispensed to the patient by the support person.

OR Management

The anesthesia team should be made aware that a patient is currently taking Suboxone. Anesthesia providers are skilled at using anesthetic techniques (such as inhalational agents) and at carefully titrating narcotics to proper efficacy. The use of various regional anesthetic techniques, including simple field blocks, can greatly help in the management of these patients. Non-narcotic analgesics can also be used where indicated.

PACU Management

Patients on Suboxone who are in pain can be given traditional narcotics in the recovery room. Understanding the pharmacology of buprenorphine/naloxone enables providers to titrate post-op narcotics gently and appropriately. Staff should diligently monitor the respiratory rate while gently titrating postoperative narcotics in the recovery room. Respiratory depression remains the principle side effect that merits extreme vigilance.

Post-op Management

There’s no consensus regarding the discharge of patients on Suboxone. One thing to consider is the risk of restarting the patient’s narcotic addiction problem. I advise my surgeon colleagues to treat these patients as they would treat a standard patient with one exception: It is incredibly helpful if the patient has strong support people to help monitor pain medication use in the immediate post-operative period. Patients should be transitioned back to their Suboxone around the time the surgeon would normally move patients off their post-operative narcotics. Remind these patients that they need to be on Step 3 of the Analgesia Ladder when they re-start Suboxone to avoid withdrawal symptoms. You should also strongly encourage these patients to resume active counseling for their addiction.

About the Authors:

Dr. Kunkel (fak9717@hotmail.com) is a board-certified, practicing anesthesiologist in Cranberry Township, Pa, and is also board-certified in Addiction Medicine by the American Society of Addiction Medicine. Katherine Kunkel will be entering medical school in the fall of 2009.