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By Dr. Frank A. Kunkel and Katherine J. Kunkel
Introduction
Pain specialists who treat pain patients are frequently consulted about narcotic management issues. The generally accepted therapy for narcotic addiction involves cognitive-based therapy, such as Alcoholics Anonymous, Narcotics Anonymous, private meetings, etc. However, these patients experience extreme craving for narcotics, and medication use has evolved to help these patients pharmacologically while they strive to overcome their addiction.
One such drug used in the treatment of narcotic addiction is buprenorphine hydrochloride/naloxone hydrochloride dihydrate (Suboxone®), and it has profound implications for patients undergoing anesthesia and operative intervention. This medication is a sublingual tablet used to treat opiate addictions. The naloxone component of the tablet is not bioavailable sublingually. Buprenorphine is in the class of narcotic agonist/antagonists. The medicine works by binding to opiate receptors to provide a modest level of analgesia. However, Suboxone exhibits a 'peak ceiling effect' leveling its analgesic and side effect profile. Since buprenorphine has a very high affinity for the opiate receptor, other narcotics will have decreased receptor binding.
Traditional narcotics given at standard doses intraoperatively will have decreased analgesic effects on patients taking Suboxone. Unfortunately, many perioperative caregivers aren’t familiar with the treatment of narcotic-addiction patients. The key to appropriate treatment of acute pain (including perioperative) in the patient on Suboxone lies in educating medical providers on its pharmacology and supplying some general guidelines on its perioperative uses.
A Simple Explanation about Suboxone®
Imagine a ladder with ten steps. Step 0 is a patient who has no narcotics in the system. Step 10 is a patient on very high doses of narcotics. When patients with a narcotic addiction (sitting on Step 7 of the ladder) let their narcotic levels fall, they begin to experience withdrawal once they fall below Step 3. This withdrawal syndrome is profound and includes profuse sweating, cramps, diarrhea, agitation, and mood changes. Narcotic-addicted patients who fall below Step 3 of this ladder describe withdrawal symptoms as 'unbearable.'
Upon taking buprenorphine/naloxone, the patient achieves a balance between withdrawal syndrome and narcotic craving—essentially, the patient is on Step 3. If someone who is on Step 7 or higher of this ladder takes Suboxone, that person will instantly 'plummet' to Step 3. This rapid fall will induce the typical withdrawal syndrome. Therefore, patients, when first starting Suboxone, must wait until they begin to experience withdrawal, and then they can take Suboxone to raise them to Step 3.
Recall also that Suboxone has a very high affinity for the opiate receptor (think, Suboxone does not want to be pushed off of Step 3). Therefore, if an addiction patient takes hydrocodone/acetaminophen it will typically have little or no pharmacologic effect because Suboxone holds the patient at Step 3.
Can addiction patients on Suboxone overdose on narcotics? They certainly can if they take a high dose of a narcotic. Suboxone has a high affinity for the mu opiate receptor, but it can be displaced by high dose narcotics. The typical dose of Suboxone is between one and three tablets daily. The drug has a peak ceiling effect, meaning that if the patient takes more than three pills daily, he or she will not go higher on the ladder than Step 3. This ceiling effect is one of the great advantages of Suboxone, which deters its potential for abuse.
Suboxone will provide some analgesia (Step 3, remember), but its primary indication is for the treatment of narcotic addiction. If used inappropriately, such as dissolving and injecting it, the naloxone becomes bioavailable and the patient will go immediately to Step 0 on the ladder.
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