Pre-op Suboxone taper

[wsoko]

Hey guys maybe someone can help me here. I've been on 20 mg of Suboxone for a year and in 2 weeks I have spinal surgery and the surgeon warned me I would be in a lot of post-op pain and I explained how I'm on Suboxone and didn't know how Percocet would work given how much Suboxone I'm on. I'm just wondering what you guys recommend in terms of a taper so that I'm able to actually feel the Percocet post-op. I have a feeling I would need to be off it for at least a few days but is the benefit really worth going through withdrawals until my surgery? I think not.

 

[Coffeeshroom]

2 weeks, 14 days eish brah. Only quick method I can think of is
Suboxone to methadone to oxy. With a rapid taper when on methadone. But like I said "eish brah" tough one but do able with the right resources and will power.

 

[DeathIndustrial88]

Any doctor with some dignity & respect would take your situation into account & hopefully prescribe you a more potent opioid that will match your tolerance or even break through the Suboxone.

Idk where you're from, but in the US, you can have half your face & limbs dangling off & still be called a drug addict for seeking pain relief. So I would expect the worst thanks to our ignorant war on opioids.

 

[wsoko]

Yeah you're absolutely right. And I was completely upfront with all the doctors involved in this process about the fact that I'm on Suboxone and I have had addiction issues in my life but the Suboxone doctor telling me to reduce my dose by half the day before surgery just seems a little ridiculous to me. I've been on it for a few years so my receptors are saturated with it. There is no post-op med they can give me that will break through it unless it's maybe fentanyl which of course they'll never give. But yeah you can feel and see the judgment every time.

 

[sadboi]

Any doctor with some dignity & respect would take your situation into account & hopefully prescribe you a more potent opioid that will match your tolerance or even break through the Suboxone.

Idk where you're from, but in the US, you can have half your face & limbs dangling off & still be called a drug addict for seeking pain relief. So I would expect the worst thanks to our ignorant war on opioids.

Yep doctors too scared of being called an over prescriber now. Under prescribing is the norm. They gave me 15 hyrdocodone 5’s for a highest grade ankle sprain that i couldnt put weight on for months. Tore ligaments off the bone. Its so bad here that i was actually surprised they gave me anything. Next doctor acted like 1st doctor was dr feelgood and wouldnt even consider a refill. I was like i guess im filing workers comp and staying off it for a long ass time. A month in i was in agony and the doctor said whats your pain level? I was like 7 and he scoffed and said it shouldnt be a 7 after a month. I was like what the fuck did u ask me for it you already know. He had a pair of vans on and i had one cowboy boot on and the other just the boot thing. “I wish you could work in a well lit area on even ground” like a complete smart ass. he wrote me some steroids to waste my time. Never going to put myself through that humiliation again unless the World starte recognizing pain killers are one of the best things about modern living and go back to perc 10’s for as needed pain. I get Oc 80’s were a lil wild but taking perc 10’s off the shelf because the mds all gave out 80’s for toothaches aint the publics fault.

 

[Jen X]

Welcome to the group. I would start tapering. I didn't find suboxone help with pain at all. Taper and when you're down to 1-2mg stop and have 2 slightly uncomfortable days. Back when i was on subs when i was down to 1-2mg it would take 2 days to feel the full effect of any other painkiller.

Or if that don't work for you try to get some short acting opioid and taper down using the short acting to get some sleep

 

[DeathIndustrial88]

Yeah you're absolutely right. And I was completely upfront with all the doctors involved in this process about the fact that I'm on Suboxone and I have had addiction issues in my life but the Suboxone doctor telling me to reduce my dose by half the day before surgery just seems a little ridiculous to me. I've been on it for a few years so my receptors are saturated with it. There is no post-op med they can give me that will break through it unless it's maybe fentanyl which of course they'll never give. But yeah you can feel and see the judgment every time.

Hope it goes well man!

I've been on Suboxone 8 years & I can still break through with weaker opioids.


Try taking 2mg or less daily instead of your usual dose. You don't even have to quit the suboxone altogether.
After a few days, you could technically get a full agonist to work.

Hell, I use to take low dose bupe to potentiate my heroin or full agonists back in the day. It's all about dosage and timing. Take a small dose of bupe in the beginning of your day & then take your full agonist through out the day. Your receptors may be saturated right now but it only takes a few days of lower dosing before your receptors open up. The full agonist won't be as strong as it would if you weren't on suboxone, but it's still possible to get something out of them.

It may be impossible to break through (safely) on higher doses of bupe, but you could still get this to work.

So I would take low doses leading up to your appt & you'll have better luck. I can feel weak stuff like hydrocodone when my sub doses are low. It's not euphoric, but it's there.

Tramadol tends to synergize nicely with bupe too for some reason. 400mg of tramadol + 1-2mg of buprenorphine is ALMOST as good as the real deal.

 

[Jen X]

Hope it goes well man!

I've been on Suboxone 8 years & I can still break through with weaker opioids.


Try taking 2mg or less daily instead of your usual dose. You don't even have to quit the suboxone altogether.
After a few days, you could technically get a full agonist to work.

Hell, I use to take low dose bupe to potentiate my heroin or full agonists back in the day. It's all about dosage and timing. Take a small dose of bupe in the beginning of your day & then take your full agonist through out the day. Your receptors may be saturated right now but it only takes a few days of lower dosing before your receptors open up. The full agonist won't be as strong as it would if you weren't on suboxone, but it's still possible to get something out of them.

It may be impossible to break through (safely) on higher doses of bupe, but you could still get this to work.

So I would take low doses leading up to your appt & you'll have better luck. I can feel weak stuff like hydrocodone when my sub doses are low. It's not euphoric, but it's there.

Tramadol tends to synergize nicely with bupe too for some reason. 400mg of tramadol + 1-2mg of buprenorphine is ALMOST as good as the real deal.

My old methadone doctor said that at 4mg most receptors are full. Dunno how true that is but when they microdose people they stop the full agonist when you reach 4mg of suboxone and you don't get sick.

 

[sadboi]

Welcome to the group. I would start tapering. I didn't find suboxone help with pain at all. Taper and when you're down to 1-2mg stop and have 2 slightly uncomfortable days. Back when i was on subs when i was down to 1-2mg it would take 2 days to feel the full effect of any other painkiller.

Or if that don't work for you try to get some short acting opioid and taper down using the short acting to get some sleep

Same here suboxone blocked any and all opiates for me at any dose. this guy saying he feels opiates while being on them for 8 years and used to use it to potentiate heroin is a rare case.
I and everyone i know had to quit subs for at least 3 days but me personally would be a week for full effect. Methadone blocks oxycodone for me at 120mg completely. Im on 70 mg now and havent had the desire to try and see yet because i think it would block even after a couple skipped doses.

 

[sadboi]

Hey guys maybe someone can help me here. I've been on 20 mg of Suboxone for a year and in 2 weeks I have spinal surgery and the surgeon warned me I would be in a lot of post-op pain and I explained how I'm on Suboxone and didn't know how Percocet would work given how much Suboxone I'm on. I'm just wondering what you guys recommend in terms of a taper so that I'm able to actually feel the Percocet post-op. I have a feeling I would need to be off it for at least a few days but is the benefit really worth going through withdrawals until my surgery? I think not.

I replied further down but i wouldnt take subs for minimum 3 days. Just got for as long as you can hold out. Good you were honest with them hopefully have an intelligent doctor with a little empathy. Your dose is kind of high but you should be ok at 3 days but ideally 5-7 and definitely take less than 20

 

[DeathIndustrial88]

My old methadone doctor said that at 4mg most receptors are full. Dunno how true that is but when they microdose people they stop the full agonist when you reach 4mg of suboxone and you don't get sick.

Here's a receptor occupancy chart.

It's true that everyone's ceiling dose is variable. But according to these charts, you don't reach full receptor occupation until after around 8-16mg

Loading…

accurateclinic.com

I find 4-8mg to be my personal ceiling/blocking dose. As in, if I'm taking more than 4mg a day consecutively, I am going to need a good 12-24hrs of no dosing in order to feel a full agonist.

But if I'm taking .5mg-2mg a day, I can absolutely feel a full agonist. It might be a bit muted & not as enjoyable, but I can still feel it. And theoretically, so should everyone else. I think a lot of people mistake the lack of euphoria as "blocking". But even if you don't get any euphoria or "high" from it, it can still provide pain relief that's better than buprenorphine alone. At least IME.

Same here suboxone blocked any and all opiates for me at any dose. this guy saying he feels opiates while being on them for 8 years and used to use it to potentiate heroin is a rare case.
I and everyone i know had to quit subs for at least 3 days but me personally would be a week for full effect. Methadone blocks oxycodone for me at 120mg completely. Im on 70 mg now and havent had the desire to try and see yet because i think it would block even after a couple skipped doses.

I don't think I'm a "rare case", I think most people just don't know how buprenorphine works & believe in misconceptions.

Buprenorphine is active in micrograms. I highly doubt .5mg (or any dose, as you put it) would block anything. You don't even have full receptor occupancy until you have at least 8-16mg of bupe in your blood. And this is variable for some people. Buprenorphine also raises tolerance & I think most people mistake the lack of euphoria when they take a full agonist as "oh my suboxone is blocking it"...Which could very well be the case if you're taking high doses every single day. Yet it's physically impossible for buprenorphine to "block" an opioid if your receptors aren't saturated. You may not get much effects, but anyone who knows what they're looking for can tell when they've taken a full agonist over a partial.


I also said if you're taking high doses every day, then you're going to need to wait 48-72hrs to let that come out of your body, yet you're repeating this as if I never mentioned it, which I think is misconstruing my point.

You can literally maintain on lower doses of buprenorphine in preparation for full agonist use. It's not impossible & actually follows along with the science & pharmacology of how buprenorphine works. OP is literally throwing the baby out with the bathwater because they think they're fucked because they take Suboxone. Yet as long as you lower your dose in prepartion for taking a full agonist, you can get it to work. And this isn't something a "rare case like me" can only do, anyone can do it.


Some one taking low, non-blocking doses of buprenorphine, will literally have receptors open for a full agonist to attach to. You won't get the all encompassing euphoria from it that you normally would & I think most people mistake this as "blocking", when really it's a tolerance issue. You will still get slight/moderate & even strong pain relief from the full agonist, especially depending on the dose. This isn 't something "rare" at all. It's basically why OP's doctor said he should cut his dose down in preparation, cause as long as he allows some of that buprenorphine to leave his body, it will open up receptors for a full agonist to attach.

 

[AlsoTapered]

https://www.mcstap.com/docs/Acute%20Pain%20Management%20for%20Patient%20on%20Suboxone.pdf

 

[sadboi]

Here's a receptor occupancy chart.

It's true that everyone's ceiling dose is variable. But according to these charts, you don't reach full receptor occupation until after around 8-16mg

Loading…

accurateclinic.com

I find 4-8mg to be my personal ceiling/blocking dose. As in, if I'm taking more than 4mg a day consecutively, I am going to need a good 12-24hrs of no dosing in order to feel a full agonist.

But if I'm taking .5mg-2mg a day, I can absolutely feel a full agonist. It might be a bit muted & not as enjoyable, but I can still feel it. And theoretically, so should everyone else. I think a lot of people mistake the lack of euphoria as "blocking". But even if you don't get any euphoria or "high" from it, it can still provide pain relief that's better than buprenorphine alone. At least IME.



I don't think I'm a "rare case", I think most people just don't know how buprenorphine works & believe in misconceptions.

Buprenorphine is active in micrograms. I highly doubt .5mg (or any dose, as you put it) would block anything. You don't even have full receptor occupancy until you have at least 8-16mg of bupe in your blood. And this is variable for some people. Buprenorphine also raises tolerance & I think most people mistake the lack of euphoria when they take a full agonist as "oh my suboxone is blocking it"...Which could very well be the case if you're taking high doses every single day. Yet it's physically impossible for buprenorphine to "block" an opioid if your receptors aren't saturated. You may not get much effects, but anyone who knows what they're looking for can tell when they've taken a full agonist over a partial.


I also said if you're taking high doses every day, then you're going to need to wait 48-72hrs to let that come out of your body, yet you're repeating this as if I never mentioned it, which I think is misconstruing my point.

You can literally maintain on lower doses of buprenorphine in preparation for full agonist use. It's not impossible & actually follows along with the science & pharmacology of how buprenorphine works. OP is literally throwing the baby out with the bathwater because they think they're fucked because they take Suboxone. Yet as long as you lower your dose in prepartion for taking a full agonist, you can get it to work. And this isn't something a "rare case like me" can only do, anyone can do it.


Some one taking low, non-blocking doses of buprenorphine, will literally have receptors open for a full agonist to attach to. You won't get the all encompassing euphoria from it that you normally would & I think most people mistake this as "blocking", when really it's a tolerance issue. You will still get slight/moderate & even strong pain relief from the full agonist, especially depending on the dose. This isn 't something "rare" at all. It's basically why OP's doctor said he should cut his dose down in preparation, cause as long as he allows some of that buprenorphine to leave his body, it will open up receptors for a full agonist to attach.

Yeah i see what your saying with them working at low dose without the actual high or euphoria just in a pain killing sense. Got ya

 

[sadboi]

Yeah i see what your saying with them working at low dose without the actual high or euphoria just in a pain killing sense. Got ya

You got a methadone chart similar to that bupe chart?

 

[snmfmy]

My old methadone doctor said that at 4mg most receptors are full. Dunno how true that is but when they microdose people they stop the full agonist when you reach 4mg of suboxone and you don't get sick.

Not true regarding receptor occupancy.

The reason they stop giving you the agonist is because buprenorphine at 4 mg provides about 50% mu opioid receptor occupancy and that is the level that prevents withdrawal.

(Quote is from the paper cited below)

"Withdrawal suppression appears to require ≤50% μOR availability, associated with BUP trough plasma concentrations ≥1 ng/mL; for most patients, this may require single daily BUP doses of 4-mg to defend against trough levels,"

To get to opioid blockade for reasonable doses of opiates to prevent the reinforcing and pleasurable effects, you must get to 80% occupancy, meaning only 20% of the mu receptors are still available. This level equates to a serum level of 3 nanograms/ml or higher. Most people normally need 16 mg a day or higher of buprenorphine to reach a consistent 3 nanograms.

To prevent breakthrough of high dose opioids even higher daily doses of buprenorphine would be needed.

"Blockade of the reinforcing and subjective effects of typical doses of abused opioids require <20% μOR availability, associated with BUP trough plasma concentrations ≥3 ng/mL; for most individuals, this may require single daily BUP doses >16-mg, or lower divided doses.

For individuals attempting to surmount this blockade with higher-than-usual doses of abused opioids, even larger BUP doses and <10% μOR availability would be required."

Buprenorphine maintenance and mu-opioid receptor availability in the treatment of opioid use disorder: implications for clinical use and policy

Sublingual formulations of buprenorphine (BUP) and BUP/naloxone have well-established pharmacokinetic and pharmacodynamic profiles, and are safe and effective for treating opioid use disorder. Since approvals of these formulations, their clinical use ...

www.ncbi.nlm.nih.gov

 

[snmfmy]

Here's a receptor occupancy chart.

It's true that everyone's ceiling dose is variable. But according to these charts, you don't reach full receptor occupation until after around 8-16mg

Well, here's an actual NIH study that measured occupancy and doses required to maintain it.

They indicate that full receptor blockade requires doses well above 16 mg a day.

4 mg = greater than or equal to 50% occupancy -- withdrawal symptoms suppressed

"Withdrawal suppression appears to require ≤50% μOR availability, associated with BUP trough plasma concentrations ≥1 ng/mL; for most patients, this may require single daily BUP doses of 4-mg to defend against trough levels, or lower divided doses.

Greater than 16 mg = greater than or equal to 80% occupancy -- blockade of normal recreational opiate doses

"Blockade of the reinforcing and subjective effects of typical doses of abused opioids require <20% μOR availability, associated with BUP trough plasma concentrations ≥3 ng/mL; for most individuals, this may require single daily BUP doses >16-mg"

Apparently to provide blockade against higher doses of opiate medications, you need to have greater than 90% receptor occupancy which apparently requires higher doses than even greater than 16. Although I don't know how they quantify that.

"For individuals attempting to surmount this blockade with higher-than-usual doses of abused opioids, even larger BUP doses and <10% μOR availability would be required."

Buprenorphine maintenance and mu-opioid receptor availability in the treatment of opioid use disorder: implications for clinical use and policy

Sublingual formulations of buprenorphine (BUP) and BUP/naloxone have well-established pharmacokinetic and pharmacodynamic profiles, and are safe and effective for treating opioid use disorder. Since approvals of these formulations, their clinical use ...

www.ncbi.nlm.nih.gov