Buprenorphine and Full Agonist Opiates for Acute Pain

[Sasquatchjezus]

Hey y'all
So heres a hypothetical:
I go and break my femur or coccyx, or some extremely painful bone to break. I go to the hospital screaming in agony. But, I'm a buprenorphine patient. I take 4mg in the morning and 4mg at night. I don't take buprenorphine/naloxone, I take generic subutex -->(Buprenorphine), (in the US, I'm pretty sure that the brand name isn't marketed anymore) which is buprenorphine only; no naloxone, and know this doesn't make a difference b/c I dont iv it. So... Am I screwed for 24-48 hours (I have a fairly fast metabolism and take it twice daily for chronic pain)? Or is there a full opiate agonist that will save me from that long agony? I know that precipitated w/d can occur even with buprenorphine single ingredient tablets. As far as I know, no full opioid agonists can be administered with buprenorphine without the looming threat of precipitated w/d (let alone respiratory depression), but have heard a few people say that hydromorphone or fentanyl can be used in these scenarios. This is something I've been worried about a little for a while, it's always a thought in the back of my head. The thought usually being that even if I can be administered full agonists, I'll encounter some nazi doctor will think "oh screw that junkie, I'm not losing my medical license/DEA # just to provide adequate analgesia to him, I'm a sadist; I like seeing people in pain. It gets me off... Give him some APAP/PCM or something; I don't care that he broke his left femur and clavicle."; or something like that. Is this fear justified? Or were those people who gave me that potentially incorrect information right? Let me know if this is in the wrong thread and if I should put it in advanced drug discussion or something before taking the post down so that I can move it there, and thank you in advance for doing that if you are willing to do so. Thank you for your time as well.
-Sasquatch Jesus

 

[Keif' Richards]

Hey, I know this guy! I read your paper by the way dude. It was excellent.

So, this is a hypothetical scenario right my man? You are correct that, as always, the MD/PA/APRN = "prescriber" is the gateway between you and the care that you actually require. This is actually a fairly straightforward issue, being heavily dependent upon the aforementioned opinions of the one handling your care. If you are in a hospital, you should be able to easily request something called a "Pain Team" or something similar.

Just like how there is usually an "IV Team", the Pain Team is called in whenever a prescriber feels out of their depth. When an nurse can't find a vein, similarly, they call someone who specializes in the procedure. You absolutely can treat pain adequately while dependent upon Opioid Agonists. It is a significantly more complicated issue, think anesthesia, but it can be done.

10 years ago, I would've told you that you are 95% fucked. In our current climate, more docs are more educated about Buprenorphine and addiction in general (still don't know shit generally, but it's an improvement).

There are drugs like Remifentanil (Ultiva) that are super, duper potent, just to name one. In your situation, the problem is not so much the "breaking through", but the math and monitoring required to adequately treat the pain, titrate off the Buprenorphine and then slowly go back up once acute analgesia is not required. As you might have expected, there seems to be an inevitable period of abstinence from all Opioids lasting up to 36 hours. During this period, they will most likely withhold your Buprenorphine, while slowly inducting on an acute Opioid agonist.

Once you are out and don't require the pain management anymore, you simply repeat the same process that you went through when you first started your Buprenorphine maintenance. They will likely do all of this in the hospital so that you leave essentially the same way you came out. Here is a helpful article that puts it more eloquently than I ever could.

https://pcssnow.org/wp-content/uploads/2014/03/PCSS-MATGuidanceTreatmentOfAcutePainInPatientsReceivingBup.Fiellin.pdf

Let me if anything else is needed and I'll talk to you tonight.

 

[CfZrx]

They will def use fent or some such super-opioid in the case of extreme acute pain. No need to stress. Side note, I used FeNt as a bridge from my last dose of methadone to buprenorphine, and it was painless. I can't believe that method isn't discussed more. They always say it's so hard to switch from M-Done to Sub. :D

 

[Gaffy]

I once broke my ankle while on a fentanyl bender (30-50mg day) and arriv9ng at the hospital my pain was starting to grow as the fentanyl was wearing off. They straight off gave me a pill with a mixture of MDMA (you read that right) and a very strong benzo which at first got me so high I didn"t feel the pain anymore but kept me awake long enough for radios etc, then made me fall asleep for the operation table. When I woke up 12h later I had been put on Haldol+Suboxone for withdrawals and didn't feel any real pain anymore. So that's that.

 

[Keif' Richards]

I once broke my ankle while on a fentanyl bender (30-50mg day) and arriv9ng at the hospital my pain was starting to grow as the fentanyl was wearing off. They straight off gave me a pill with a mixture of MDMA (you read that right) and a very strong benzo which at first got me so high I didn"t feel the pain anymore but kept me awake long enough for radios etc, then made me fall asleep for the operation table. When I woke up 12h later I had been put on Haldol+Suboxone for withdrawals and didn't feel any real pain anymore. So that's that.

Can we kindly have the addendum to this story? I am not familiar with any such treatment. Crazy!

 

[euphoricc]

please keep us updated i am on sublocade has been for 2 years this alway`s scared me and now with covid i pray my immune system is ok with 10+ year`s of bupe~!!!

 

[G_Chem]

So I just dealt with a similar situation this past winter... Although I’m on 1mg Suboxone a day, which is much much less than 8mg and usually not considered a “blockade dose.” I think this is why I didn’t respond sooner but with Covid I got all the time in the world

I had been dealing with painful cancerous tumors for awhile and was hesitant to go in because I knew how they might treat me cuz of my past. I live in a new state and have been clean off heroin over 10yrs, but even then I was worried they might find out so I was honest from the start.

When the day came for surgery they leveled with me and we agreed that we would try non-opioid medications at first but if need be we could use opioids. They made it clear my pain management was top priority and with my obvious stability their worries were minimal.


All that said, I refused them and went about seeking my own opiates before the surgery ever took place. I managed my own pain because I knew the risks of getting them prescribed were too great. What if they don’t give me enough? (Likely.) what if they perceive addict behavior when there is none?

In my mind the best route was to remain a good clean boy in their eyes taking their Gabapentin as pain management. While I secretly used the correct amounts of opioids needed for my pain levels and tapered as soon as the pain subsided. Using microdoses of Ibogaine to make the final push.

For anesthesia during surgery they used Ketamine, Gabapentin, Benzos, local, etc.. Worked like a charm.


Moral of my story?.. Idk. I guess to tell you that while you may be get ok treatment, the chances are it will still be inadequate as they try to keep every drug they give you to a minimum.

From here out I’ll akways have some full agonist opiates Incase of another major injury, cuz the worry is real.

All that said, having to do it all yourself is like playing with fire. The only person who can stop you is you.

-GC

 

[Gaffy]

Can we kindly have the addendum to this story? I am not familiar with any such treatment. Crazy!

I looked addendum up and it says it's an addition of information to a contract. What I wrote is pretty much all I can tell about that story ^^. It was in a French hospital reputed for its nurseries and knee/ankle surgeon, lucky me! I searched for medications containing both a downer and an upper and all I found was Dexamyl, which is still in use in Hospitals in France, probably because it is abused by the nurses and other staff.