Management of Patients Taking Suboxone

Suboxone is a mixed opioid agonist/antagonist, with buprenorphine as its active ingredient. Suboxone has a high affinity for the opiate receptor which can block the effect of other narcotics if taken in conjunction with it. It provides analgesia and euphoria but its primary indication is for the treatment of narcotic addiction. When patients with narcotic addiction let their narcotic level fall below their threshold, they begin to experience profound withdrawal syndrome producing sweats, cramps, diarrhea, mood swings, and agitation. Although suboxone can be displaced by higher doses of narcotics, it generally holds patients at a level which curbs withdrawal and craving, while it keeps them from moving up their narcotic level when they take perioperative opioids. Suboxone is typically given between one and three tablets sublingually daily. The other unique feature of suboxone is its having a peak ceiling effect; therefore, patients will not step up their narcotic level even if they take more than the recommended daily dose. This is another great advantage of the drug in deterring its abuse potential. The naloxone in suboxone is not bioavailable sublingually and its main role is to deter inappropriate use of the medication.

There is no gold standard for treating patients taking suboxone before elective surgery. Careful titration of perioperative narcotics with appropriate monitoring for side effects remains the mainstay of treatment. Typically, specalists recommend that suboxone be stopped for 2-3 days before elective surgery to make traditional opiates be more effective as its level falls. Patients are prescribed short-acting narcotics such as percocet for a couple of days to ward off withdrawal as they stop taking suboxone in anticipation of elective surgery. In the operating room, narcotics should be continuously titrated to effect, may use regional anesthesia techniques and field blocks, and consider using non-narcotic analgesics where indicated. In the recovery room, traditional narcotics should be used when patients are in pain. Postoperative narcotics need to be titrated gently and appropriately, as respiratory depression is the principal side effect that merits extreme vigilance. Alternatively, other clinical providers continue patient's baseline suboxone dose into the operative period and titrate additional short-acting opioids as necessary to control perioperative pain. There is no consensus regarding the discharge of patients in suboxone. The risk of restarting the patient's narcotic addiction needs to be considered. Patients should be transitioned back to their sub-oxone around the time patients are moved-off their post op narcotics. To avoid withdrawal symptoms, patients need to be in their prior narcotic level when they start suboxone.

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