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Misc Polydrug addict/ Bupe patient getting a wisdom tooth extraction...

tom80

Bluelighter
Joined
Mar 9, 2006
Messages
117
(I know there's another thread about wisdom tooth extractions, but I didn't want to bump an old thread that's 4 pages long, as I have a specific question)


I've been putting this off for a while, but I need to get a wisdom tooth extraction soon and made an appointment for a consult and xray next week. This oral surgeon is highly recommended and has a good reputation. He doesn't offer nitrous oxide/gas anesthesia, so my 2 options are either a shot in the gums for local anesthesia OR a shot in the arm with IV anesthesia and sedation. I'd like to go with the latter (eventhough its $450 extra, its well worth it) since I get nervous when it comes to dentistry. Here's the problem..I'm RX'd Suboxone 8mg and Ativan 6mg (per day for each) and I'm debating whether or not to tell him about that. I live in the US, so since we don't have socialized medicine there's no way for him to know my medical history without me telling him.

I don't want the "junky" stigma and be screwed out of getting proper IV sedation and pain management during the extraction. I won't do the procedure without atleast nitrous (and like I said, that's not happening). On the flip side, I'm afraid if I don't tell him what I'm on that I'll be screwing myself and not get sufficient sedation, fearing waking up during the procedure. I plan on taking a break from the Sub for a short period (please, no lectures on relapse) because of this procedure (before and afterwards). I'm a pussy and can't deal with the post op pain without opiods (well I'm sure I can, but I won't). With my massive tolerance to opioids though, whatever he might RX me afterwards, whether it be T3's or 10mg percs, will do nothing. So of course I'll be getting most of my post op meds elsewhere. Speaking of that, my primary ROA is intra-nasal, so will snorting affect the post op healing process (I'll be getting stitches BTW)?

So I was hoping someone reading this has some advice/gone through a similar experience/would like to comment. And before anyone asks, I currently only plan on taking 1mg of Ativan before I walk into the office before the extraction. NO opioids of my own beforehand since I don't want to look high to him or OD.

Thank you for taking the time to read this.
-Tom
 
You need to tell your dentist about the sub/ativan before getting sedation.

The sedation is generally a combination of fentanyl and versed, and since you are already on a high dose of benzos as well as a partial agonist opiate there could be complications.
 
The way I see it you have 2 options you can tell him your on suboxone for pain which is believable if you say buprenorphine not suboxone. The other option is stop the sub a week before surgery and switch to whatever opiate you like then use that opiate plus whatever he scripts you for pain I got Demerol! Either way tell him about the ativan no reason not too.
 
You need to tell your dentist about the sub/ativan before getting sedation.

The sedation is generally a combination of fentanyl and versed, and since you are already on a high dose of benzos as well as a partial agonist opiate there could be complications.

Possible complications as in OD'ing from what he gives me or waking up because of my high tolerance?

And wouldn't the bupe block the fentanyl? That's why I'm taking a break from it.
 
I'm pretty sure that IVing fentanyl could easily break through the blocking effect of suboxone, but from what I've read, that can be rather dangerous because of the high dose that would be needed.
 
Dude, I wouldn't tell your dentist anything about being on suboxone and ativan. He will most likely not sedate you enough, if at all, or give you adequate post operation pain meds. There are pain meds that can break through low dose suboxone, like fentanyl. Some people say they even have luck with tramadol working while on suboxone. But in my experience, once people know you're on subs or methadone, they stigmatize you. For example, when I developed a corneal ulcer, I was honest and told the eye doctors about being on suboxone. Keep in mind, the pain I had was almost unbearable, even with being on suboxone everyday. They didn't even give me a script for 800mg motrin. And when I went in for the 3rd visit and asked about what would be done for this terrible pain, the asshole doctor told me to take aleve. So don't tell this dentist shit about your personal chemical intake. At worst, you could be prescribed some percs for when you might have to stop taking subs for whatever reason. A rainy day type thing. Good luck.
 
Very good question tom80. When I was on Suboxone, I always worried/wondered what if I had to have some kind of surgery or was in an accident and they needed or just gave me morphine or dilaudid or something, the bupe would block it a considerable amount, especially at the doses they give normally and a higher dose could risk added CNS depression. But if you do tell the dentist (which is probably the best idea), he COULD judge you and not let that even be an option. So its hard to say really. You'll prolly just get the gum shots and be in some pain most likely unfortunately. Plus, if you get fentanyl/versed, that could risk you relapsing since you are on suboxone and most people are on it for opioid dependence...good luck though.
 
Crimson, the DR that prescribes me Ativan is the same Dr that prescribes me Suboxone. So I can't hide one med or the other from the oral surgeon.

Poppyplanet, that's horrible and quite frankly inhumane that your Dr told you to take Aleve for a corneal ulcer! That kind of bullshit is the problem with getting labelled an addict, and is why I've decided NOT to tell him about my Sub use. Dr's and people in general look at addicts in a completely different light...and assume the worst.

Chris, I have the same exact fear..not just from being on sub, but even on full agonists with my massive tolerance (I'm not going to dicksize, but I HATE and am AFRAID of how high my tolerance is). So like I said, I'm going to take a break from the Sub for a while until my post op pain is tolerable. I'm debating whether or not to tell him about my high tolerance to full agonists though..even if I get Fentanyl (which I've never had), I'm sure it'll be a dose for the average person. So I'm debating whether or not to take a mild dose from my own stash before I walk into the office for my procedure.
 
Fentanyl will not break through bupe at 8mg - that is way too high a dose.

Bupe is an antagonist as well as an agonist so you MUST tell the dentist about it. If I were you, I would kick the bupe about 2 weeks before the procedure and just say nothing. Or, stay on it but don't have the procedure.

Opiate-type drugs are used in anaesthesia. You're on an opiate agonist/antagonist. That means that you could conceivably not be sedated enough and wake up during the procedure, or be too sedated and die from respiratory depression.
 
How much bupe did you say you take per day? If you can taper down to 2mg right now(and lower than that the week of the surgery if possible) and don't dose for at least 24 hours(48 would be better) then you'll be fine. Tolerance shouldn't be an issue but attentuation would be, assuming you haven't been on some really high dose of bupe and it has built up to a crazy level in your system. The anesthesis is gonna keep giving you fentanyl until your vitals are where he/she wants em...if you got a tolerance they will just overcome it...if you are attenuated with bupe they might OD you.
 
Like I said, I will take a break from the bupe before and after the procedure. I will stop taking it beforehand and switch back to my full agonist. I know how bupe works and at 8mg/day it would block the fentanyl. I've only been on it for two weeks this time (was on 16mg/day the first week). I've been on it before and relapsed last time. After being on 16mg/day for three months, I waited for about 24 hours with no bupe, and felt about 75% of my full agonist dose. Half a day later I felt %100 of the next dose. I attribute that to my fast metabolism, but I'm no expert so maybe its due to something else.

Anyway, with the bupe out of my receptors during the procedure, wouldn't the unusually large dose of fentanyl (and the benzo) they would have to use to sedate me arise suspicion? I'm not telling him about my Sub use or tolerance due to fear of being stigmatized, and can't tell him about my Ativan use because I get both meds from the same Dr.

BTW, how could I possibly OD under the anesthesia if they're monitoring my vitals?
 
my sub doc said even being on bupe, and youre in a car accident or some serious injury and surgery needs to be done, it can be broken through with high doses of whatever opiate. ive done it with methadone, loperamide, etc. im at 8mg/day of suboxone for 2 years now. you can pump enough fetanyl or whatever and it will bind to something once there is enough in you, regardless of the suboxone. what you dont want is that damn thing that covalently bonds to you pain receptors. thats endgame right there
 
I'd most definitely tell the dentist because you never know what complications you could have with a surgical procedure and if they need to take action to save your life, not knowing that information could hinder their ability to do so.
 
what you dont want is that damn thing that covalently bonds to you pain receptors. thats endgame right there

Pardon my ignorance on the subject..but what exactly (or generally) happens with a covalent bond in pain receptors, and why is it dangerous? I vaguely remember from undergrad intro chem class about covalent bonds, but know nothing about it biologically.

Thanks for the warning.
 
Tell your dentist. It would be foolish not to. Your doctor can't treat you correctly without this knowledge.
 
My tolerance has never caused a problem when going under(and I have a huge one), been under while both having a full blown habit(didn't dose for 24 hours before) and while in bupe, twice on bupe, one time I quit dosing 48 hours before(was taking 4-8mg a day) the other time I was only taking 1-2mg per day and I just took 1mg the week, .5 2 days before, and skipped the morning of.

If you go in on bupe and are attenuated then they will probably never give you enough fentanyl to make you go under....but if they did just keep giving you more then they are going to OD you before symptoms of the OD even appear.
 
I remember when I went into get mine taken out I had a very high opiate tolerance and I do remember kind of wakening up at the beginning of the procedure but they kept adjusting the meds tell I was completely out and next thing I know its over and I am coming too.

Even before I was dependant on opiates and benzos they have always had trouble knocking me via the typical “twilight” opiate/versed combo.

I remember when I was young I was having a colonoscopy and after I came too, I was told that they were not able to go as far as they had wanted and had to finish the procedure early because they could not keep me sedated. I remember the nurse and Dr said that they had given me more medication that they would usually give a full grown man, but I kept waking up and fighting them. They said they eventually got to the point where they had given me such large doses that they didn’t feel comfortable going forward so they ended the procedure early.

This happened one more time except this time I warned them that is was going to take a lot to knock me out so they were prepared. Still had trouble and I remembered a little but it went a lot better. Now every time I have a colonoscopy I actually get true full anesthesia rather than twilight (fent/versed).

I have also had accidental painful traumatic injuries while on Suboxone and they never had trouble breaking through it with fent.

Keep in mind it you are having it done by an oral surgeon they should be prepared for ventilation and intubation if necessary, they should also be prepared with antagonists for both the benzos and opiates in case they need them so I really do not think OD should be a concern.

My suggestion would be to call now and set up a consultation with the surgeon and be honest with him and from there devise a plan to deal with your specific needs. He may prescribe you something short term to start taking a week prior in instead of the Suboxon, or he may just tell you to skip your morning dose the day of the operation and he will just adjust his meds accordingly.

My understanding is that in procedures such as this they continually adjust doses to the persons needs, and they continually administer meds as needed to maintain a certain level of sedation which I am sure they have some standardized indicators that they follow.

I really don’t think you have to worry about them overdosing you as any place that is using intravenous fentanyl, sufentanyl and midazolam is going to be very prepared for any adverse reaction including overdose.

If you do not want to talk with the surgeon doing your surgery then just stop your Suboxone a week before, use what you can to get by at the lowest dose and go in just like any one else. Your probably going to need to go to the streets for after care meds because the best your going to get is maybe 30 10/325 perks.
 
I have not seen a dentist use fentanyl. They may not even have it in their office. The typical protocol is Demerol +/- midazolam with regional lidocaine blocks.

Here's what I would recommend: tell your dentist exactly what drugs you are taking. You may have to explain
that because you take Suboxone the typical pain protocol may not work. He may elect to perform the procedure
in a hospital where you have access to an anesthesiologist who can develop the appropriate protocol. To do this, you may require prior auth from your insurance provider.

I am assuming that you are being prescribed Suboxone and not obtaining it illicitly.
I would get your prescribing physician in on the discussion.

I had to do all of this when I had a root canal, which didn't hurt at all, it was the
tooth root abscess that hurt.

If you decide to taper your Suboxone dose on your own (which I wouldn't recommend),
remember that bupe has a half-life of ~36 hours.

Bupe is a partial agonist. Think of the opiate receptor as a door.
Buprenorphine holds onto the door knob very tightly, but only opens the door halfway.
Its ceiling effect explains why more does not equal better.

Even with a Suboxone taper, you will remain opiate-tolerant because with chronic opiate use, the central nervous system down-regulates opiate receptors.
 
Tell your DR. He might not give you good postoperative pain meds, but that's because you have a knack for taking care of that yourself, and excessively or you wouldn't be on bupe. If you tell both dr's, you could switch to a narcotic painkiller about 3-4 days before the procedure, get all that bupe out of your system, then he can knock you out and give you painkillers. Once the pain is over, back to the bupe. This will depend on how "good" you have been with the dr you are getting your sub from. If it were me, and I couldn't get good post-op meds, I'd just go get high for a few days till the pain passed. It depends on what your doc is, if you are an IV H user, this is a more serious consideration than us pharmie junkies over here stateside. If they wanna be fucks about it, then save your 450 dollars for a shit load of street opiates, and just get wasted in the parking lot, go in, have it done, come out, re-dose, then go back on bupe when you aren't hurting anymore. Either way, for them to give you an opioid painkiller and it work without endangering your life, you need to take atleast 2-3 days off. You don't want any of what they give you blocked. If you have to go in there dope sick as hell just remember when they give you the needle, you will be ok for at least 12 hours, plan ahead.
 
Unless he is just going to get a little gas, a lidocaine shot and a pair of extracting pliers then he is going to an oral surgeon not a dentist.

An oral surgeon will have access to (and use it on a daily basis) fentanyl and maybe even some of its analogs (sufent), no question.

I think you are correct that Demerol did used to be the drug of choice for “twilight” but I think it has really fallen out of favor in the US with fentanyl being the more popular substitute. Demerol has some unwanted side effects and some individuals have issues with the drug, while I think the fents have less side effects, shorter half lives and lend themselves better for this type of outpatient procedure (quicker recovery).
 
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