Opioids Fentanyl after Suboxone

[tmaca]

I've been taking Suboxone for years, currently at 4mg daily, usually about 9 or 10 PM. Tomorrow at 7AM I check in to the hospital for a procedure that is supposed to begin at about 9AM, during which they'll administer IV Fentanyl. In the past, when I was going to get an opioid painkiller, I've been told I needed to stop the Suboxone 24 hours ahead of time, as it is something of an opioid antagonist, and the painkiller wouldn't work as well as it should. Earlier today I was talking to the PA at the hospital, she checked my meds on the computer (she has them all, it's the same place I get the Suboxone and literally all my other meds) and she told me to take all my meds just like I normally do. Having other things on my mind at the time, I didn't think sbout the potential Suboxone/Fentanyl conflict, and didn't ask specifically about that. Now I'm worried that she might have just missed it or something.

So if I take 4mg of Suboxone tonight at 9 or 10, is it going to interfere with the action of IV Fentanyl at about 9AM? I do NOT like pain. I can cope with it better than a lot of people, a couple years ago I totalled my bike on a run, broke my leg and severed a ligament, continued on the run, riding in the pickup truck, went into the last 2 bars on the run, went to the party after, and went to the hospital about 10 the next morning. With no pain killers and without even getting drunk. But I do NOT like pain, and in this case I need to be sure the Fentanyl is going to work, especially since I'll need to remain still and not move during the procedure.

I can't call the hospital, nobody that I could ask about this is going to be there now, so I sure hope someone who knows the answer sees and answers this tonight.

 

[tacodude]

Fentanyl should break through the suboxone dose.... You could always try taking 1 mg or less instead of four so it doesn't need to breakthrough as much bupe, but you should listen to your doctor's unless you know they are talking out there ass

 

[tmaca]

I always do listen to DRs, I've spent quite a while as a certified medical rsponder. In this case, I'm concerned that the PA just overlooked the Suboxone on my meds list, and, as I said, I was rhinking about something else, so I didn't mention it. But knowing Suboxone is an opoid antagonist, and knowing not to tsake it for 24 hours prior to other opoid painkillers, this has me a little worried, and I'm hoping someone(s) out there knows a lot more about these two drugs together than I do. What I've done so far is to take 2mg of suboxone about an hour ago, hoping that will be enough to let me sleep OK tonight, and not have much effect on the Fentanyl in the morning. And I always do tell any DR. giving me any opoids that I have a higher than "normal" tolerance for and resistance to them anyway, so hopefully that'll cover it. I just hope the Fentanyl has an easier time getting through the Buprenorphine than some opoids do.

 

[tacodude]

You obviously ignored me assuming I was saying a different point completely... One last time.

Bupenorphine does not have as strong of binding affinity for the receptors than fentanyl so no matter the dose of sub a good dose of fentanyl will peel them right off the receptor and breakthrough causing full agonist analgesia. So do what your doctor said, or drop it down to one mg that last dose just in case even though I'm sure this will only cause risk as they might give you a higher dose of fentanyl than needed based on the 4mg dose, and going the night without your sub well you already know what kind of hell that might be and you need to be rested and in good strength to reduce the chance of a complication becoming fatal. I seriously hope you understand as explaining it more clearly than this will be overkill.

 

[SS373dOH]

^This. You should be good to go, but if you want you can cease use of the bup', 12-24 hrs before the surgery. The bigger issue lies in reinducing the bup', after your surgery. Wait 36 hours, and induct as little bup' as you can to avoid pwd. Good luck!


- 7nos..

 

[tacodude]

Don't wait 36 hour to induce bupe hell you'll probably be back on bupe after the surgery... Plus since bupe gets ripped off by fentanyl does bupe after fentanyl even cause PTSD? anyways I'd say wait three hours minimum if only fentanyl and recommend waiting six hours to twelve at most.

 

[Swimmingdancer]

Don't wait 36 hour to induce bupe hell you'll probably be back on bupe after the surgery... Plus since bupe gets ripped off by fentanyl does bupe after fentanyl even cause PTSD? anyways I'd say wait three hours minimum if only fentanyl and recommend waiting six hours to twelve at most.

I think you meant PWD - precipitated withdrawal - not PTSD? Precipitated withdrawal happens when you are physically dependent on an opioid and then take buprenorphine (or naloxone or naltrexone etc). The OP is not physically dependent on fentanyl. Using it ONCE should not cause PWD when they return to buprenorphine

 

[tacodude]

Yea typo thanks for the correction and confirming my hypothesis... Really there should be bupe in the system floating around ready to bind once the fentanyl is gone... It should be a really smooth transition. If the tolerance risk and withdrawal possibility from fentanyl and bupe was not so great I'd think that bupe for Matinance and fentanyl for breakthrough would be one of the better ways to go about long term management or just jumping from bupe to full agonist and back to bupe.

 

[mazda01]

I think you meant PWD - precipitated withdrawal - not PTSD? Precipitated withdrawal happens when you are physically dependent on an opioid and then take buprenorphine (or naloxone or naltrexone etc). The OP is not physically dependent on fentanyl. Using it ONCE should not cause PWD when they return to buprenorphine

i could be wrong but PWD doesn't ONLY occur in people who are dependent on an opiod, it's that all your receptors are filled with ANY opioid in which the suboxone will remove from the receptors and then not fill back up completely since bupe is only a partial agonist. also, it's of note to ask if he'll be receiving a short opioid script for after surgery recovery time as bupe in the maintenance dosage range will not be effective at controlling pain so i'm sure if he's having a major surgery which involves fent to put him out, it's going to require some recovery time pain meds in which case after your last dose of whatever that pain med is you'll want to wait 18 to 24 hours before dosing your bupe and when you do start with a smaller amount than your normal maintenance dose.

BUT obviously I am not your doctor and this should all be discussed and decided between you and him. good luck with the surgery

 

[SS373dOH]

Pwd are entirely possible, after fent' use. Just like any other opiate, if bup' is taken too soon, pwd will occur.


- hs

 

[tacodude]

Pwd are entirely possible, after fent' use. Just like any other opiate, if bup' is taken too soon, pwd will occur.


- hs

Do you have evidence? Because logic would dictate if fent breaks through bupe then bupe should not break through fent as fent if obviously stronger. There is definitely going to be a transition period if one used fentanyl and let there body get used to it only to stop and go back to bupe as of course there will be discomfort as the body gets used to receiving a higher amount of activity and no matter how many bupe molocules bind it will never match fentanyl. In theory though bupe wouldn't rip off fentanyl and just float around looking for an open receptor until the fentanyl starts breaking off revealing spaces for bupe to fill. Of course there are no avoiding w/d to say the least.

 

[SS373dOH]

I've personally have done it, and there's dozens of threads about people doing the same thing, some are quite recent actually. yes it has a higher binding affinity, thus allowing it to break through bup', for analgesic effects. However it's binding affinity diminishes in strength steadily, after peak plasma levels have been acheived.


- SS373dOH

 

[tacodude]

Ok thanks for the explication. I had a hunch it was as you explained, but just couldn't be sure.

 

[StaffWriter]

I can break thru a 2mg dose of Suboxone with a Fentanyl patch, or even something like one tablet of hydrocodone

 

[Treefa]

Well the fact that you've been on it for years, IMO, makes it a little bit harder to guess at something like this.

Even if you took only 2mg/day for years, that's still a lot of accumulated bupe in you're system. With a half life of ~24 hours +- about 10-14 depending on your metabolism etc...it tends to linger!

And honestly at 4mg/day i'd be less worried about the antagonist properties of the Bupe and more worried about potential infra-additive effects from the agonist properties of the bupe, possibly potentiating the Fentanyl.

When I say potentiation of the Fentanyl by suboxone, it's hard to say exactly what to expect but here's what you know for certain; There WILL BE a signifigant amount of Buperenorphine in you're plasma at the time of Fentanyl administration.

I'd suggest you do a little thorough research on both Fentanyl & Bupe (or ask a knowledgeable BL'er) to see which receptors are activated by each, taking note of any that may overlap.

I'm pretty sure Fentanyl is a pure, potent Mu agonist, but I may be wrong.
Buperenorphine, I believe, is a Partial(but potent) Mu agonist (especially low doses, due to norbuperenorphine, which is a potent Mu agonist but doesn't cross the Blood-Brain-Barrier easily), and is also a Kappa-receptor antagonist, and maybe some other type....I wanna say Epsilon receptors, which I have no idea what the latter effects, physiologically speaking.

I'd assume that you're in good hands....i'd remind the anesthesiologist that you took 4mg Buperenorphine when you did, as well as ANY OTHER medications....non-narcotis cause more ADRs than narcotics, technically, but then again there are many more non-narcotic meds than there are narcotic ones.
In any case they SHOULD have resuscitation equipment on hand, as well as Naloxone, etc....

Are they only giving you Fentanyl?
Depending on the procedure, around here anyway, I know for things like scopes etc....they often give a combination, I believe, of Fentanyl & Versed(Midazolam, incredibly potent benzo....should be the envy of most any Bluelighter!), so i'd just, again, be sure to mention the bupe.
Because Bupe & Fent, OR Bupe & Versed may be OK, but Bupe+Fent+Versed could be a little more than you could handle.

Good luck, OP, remember communication is key here....i'd tell the doctors of ANY substance you've ingested in the past 7 days, especially the Subs, and exactly how long you've been on them.

 

[Treefa]

Pwd are entirely possible, after fent' use. Just like any other opiate, if bup' is taken too soon, pwd will occur.


- hs

I'm not sure this is entirely correct....if his receptors are already saturated with Bupe (which they are, YEARS being the keyword here) then I'd have a hard time imagining how throwing in ONE DOSE of fentanyl in would completely dislodge all the bupe from his receptors.
In my mind, being so well established on Subs for so long, he shouldn't have any problems with re-dosing sub after the procedure (after meds wear off, of course).

Remember that Fentanyl has a half-life of some 30 minutes, and Bupe has a half-life of some 36 hours!
I believe (again can't say for certain) that for Precipitated Witdrawal to occur, one has to be DEPENDENT ON A FULL Mu AGONIST! Keeping in mind that he's already DEPENDENT on the Bupe, especially.
Am I wrong here?

I believe that One dose of Fentanyl, to a brain already saturated with bupe, will NOT cause a re-establishment of True Mu opioid dependence...I just don't think that one dose of fentanyl, on top of ALL THAT BUPE is going to have enough agonism, for long enough, to re-establish DEPENDENCE, and therefore, Precipitating acute withdrawal syndrome.
Now if Op took fentanyl for 14-21 days, it would be possible, if not entirely likely, but with one dose, I just don't think it will be an issue.

Then again i'm no doctor, so again OP i'd speak with the doctors.

 

[Swimmingdancer]

i could be wrong but PWD doesn't ONLY occur in people who are dependent on an opiod, it's that all your receptors are filled with ANY opioid in which the suboxone will remove from the receptors and then not fill back up completely since bupe is only a partial agonist.

Nope, you have to be physically dependent on the full-agonist opioid being displaced (or full agonists in general at least). Buprenorphine has a high binding affinity but low intrinsic activity at the mu receptor, so as a partial antagonist it displaces full-agonist opioids from the receptors without activating them to an equivalent level, resulting in a net decrease in agonist effect, thus precipitating a withdrawal syndrome if someone is used to those receptors being activated by full agonists. It fills up the receptors and sticks to them like glue, but doesn't have the same level of activity/effects. Not having the receptors activated as much as fentanyl activates them would not cause withdrawal in someone not dependent on fentanyl. The requirement to be physically dependent on full-agonist opioids in order to cause PWD is why people who are maintained on Suboxone can use a full-agonist opioid while they are on Suboxone and not be sent into withdrawal by taking their next Suboxone dose. There are plenty of reports of people doing that here on Bluelight. It's not some special thing about fentanyl, taking/using another opioid once or twice while on buprenorphine will not send you into PWD. Weaker opioids just may not do much if taken while you're on Suboxone.

Pwd are entirely possible, after fent' use. Just like any other opiate, if bup' is taken too soon, pwd will occur.

You were physically dependent on fentanyl. The OP is not.

 

[SS373dOH]

I'm not sure this is entirely correct....if his receptors are already saturated with Bupe (which they are, YEARS being the keyword here) then I'd have a hard time imagining how throwing in ONE DOSE of fentanyl in would completely dislodge all the bupe from his receptors.
In my mind, being so well established on Subs for so long, he shouldn't have any problems with re-dosing sub after the procedure (after meds wear off, of course).

Remember that Fentanyl has a half-life of some 30 minutes, and Bupe has a half-life of some 36 hours!
I believe (again can't say for certain) that for Precipitated Witdrawal to occur, one has to be DEPENDENT ON A FULL Mu AGONIST! Keeping in mind that he's already DEPENDENT on the Bupe, especially.
Am I wrong here?

I believe that One dose of Fentanyl, to a brain already saturated with bupe, will NOT cause a re-establishment of True Mu opioid dependence...I just don't think that one dose of fentanyl, on top of ALL THAT BUPE is going to have enough agonism, for long enough, to re-establish DEPENDENCE, and therefore, Precipitating acute withdrawal syndrome.
Now if Op took fentanyl for 14-21 days, it would be possible, if not entirely likely, but with one dose, I just don't think it will be an issue.

Then again i'm no doctor, so again OP i'd speak with the doctors.

The fentanyl has a higher binding affinity than bup', when the fent' is dosed, it should "dislodge" any remaining bup'.

I can't stress enough the chances of pwd, when going from fentanly to bup', even if it is one dose. In "theory", you would think it wouldn't occur, but it does. We can send some people into a world of hurt, if we give the green light to induct at anytime after a fentanyl dose.


- SS373dOH