Bupe and Post-Surgical Pain Management...Opinions Sought

[DeadCat (OP)]

Opinions/ Experience Wanted:

Next month I am scheduled to have out-patient surgery to clean up some old scars on the tops of my thighs. The scars were caused when a surgeopn had to drain abcesseses on both legs from a series of IMs I had given myself that turned out to be mixed with unsterile water.

The post surgical pain was INTENSE. It was the first thing I felt as the general anesthesia wore off. I was hospitalized for several days with a self-controlled pain med pump. I think it was morphine but may have been dilaudid I just don't remember. It worked but I wasn't really high.

The surgeon who is doing the new operation knows I am on buprenorphine and has agreed to give me enough opiates post-surgery and I wont take the bupe before or after. I'll taper down to as little as possible before the operation. During the operation I will be awake with Fentanyl and Versed and probably a local anesthetic.

Because we expect the post-surgical pain to last for some time, and the residual buprenorphine in my system will block most opiates, the new surgeon has agreed to give me as much pain meds as I need and then when the pain is tolerable , I'll go back to the bupe.  That leads me to my question:

What drug should I take to override however much pupe is in my system and manage the pain until the worst of it is over. I'll have 4, maybe 5 sites where old scar tissue will have been removed and sewn shut. (this will greately reduce the appearance of the scars , which now look like bullet holes).

I'm thinking maybe Fantanyl patches with something like like oral (hahaha) dilaudid or IR Oxy for breakthrough pain. Remember, I'll be in w/d if I don't substitute the buprenorphine with an opiate AND I'll need more than average amounts of pain meds (opiates) to be effective on top of whatever bupe is left in my system and (I assume) the high tolerance 12 years of bupe has left me with.

So... Fentanyl, Versed and a Local during surgery and after?:

Fentanyl (How much?) plus a "breakthrough" med?
Opana?
Reguar Dilaudids (liquid maybe?)
IR Oxycodone?
Morphine? (not my preference)

I am especially curious what the medical professionals here suggest. I've got a legitimate short-term intense pain to deal with, lingering buprenorphine to override and a cooperative surgeon. Clearly I want to make this as painless as possible but also want to use the opportunity to get a good oipate glow going as well.

What opiod is least obstructed by dupe? I always hear fentanyl but that could be wrong. I do know if I cut way down  on the bupe  a good shot of dilaudid will feel very good.I've even had morphine and low-dose bupe work together to feel surprisingly good, but I wouldn't count on it hapneing again.

Whattaya guys think?

[Sand and Water]

Opinions/ Experience Wanted:

Next month I am scheduled to have out-patient surgery to clean up some old scars on the tops of my thighs. The scars were caused when a surgeopn had to drain abcesseses on both legs from a series of IMs I had given myself that turned out to be mixed with unsterie water.

The post surgical pain was INTENSE. It was the first thing I felt as the general anesthesia wore off. I was hospitalized for several days with a self-controlled pain med pump. I think it was morphine but may have been dilaudid I just don't remember. It worked but I wasn't really high.

The surgeon whoe is doing the new operation knows I am on buprenorphine and has agreed to give me enough opiates post-surgery and I wont take the bupe before or after. I'll taper down to as little as possible before the operation. During the operation I will be awake with Fentanyl and Versed and probably a local anesthetic.

Because we expect the post-surgical pain to last for some time, and the residual buprenorphine in my system will block most opiates, the new surgeon has agreed to give me as much pain meds as I need and then when the pain is tolerable , I'll go back to the bupe.  That leads me to my question:

What drug should I take to override however much pupe is in my system and manage the pain until the worst of it is over. I'll have 4, maybe 5 sites where old scar tissue will have been removed and sewn shut. (this will greately reduce the appearance of the scars , which now look like bullet holes).

I'm thinking maybe Fantanyl patches with something like like oral (hahaha) dilaudid or IR Oxy for breakthrough pain. Remember, I'll be in w/d if I don't substitute the buprenorphine with an opiate AND I'll need more than average amounts of pain meds (opiates) to be effective on top of whatever bupe is left in my system and (I assume) the high tolerance 12 years of bupe has left me with.

So... Fentanyl, Versed and a Local during surgery and after?:

Fentanyl (How much?) plus a "breakthrough" med?
Opana?
Reguar Dilaudids (liquid maybe?)
IR Oxycodone?
Morphine? (not my preference)

I am especially curious what the medical professionals here suggest. I've got a legitimate short-term intense pain to deal with, lingering buprenorphine to override and a cooperative surgeon. Clearly I want to make this as painless as possible but also want to use the opportunity to get a good oipate glow going as well.

What opiod is least obstructed by dupe? I always hear fentanyl but that could be wrong. I do know if I cut way down  on the bupe  a good shot of dilaudid will feel very good.I've even had morphine and low-dose bupe work together to feel surprisingly good, but I wouldn't count on it hapneing again.

Whattaya guys think?

First off, im sorry you'll be going through this--ouch!!  I know there's folks who have extensive experience w/bupe here, (sorry, I don't) so hopefully there'll be some solid thoughts that may help. It's great that you've got an understanding surgeon; my first thought was can you get him & the Dr who scrips your bupe to talk & come up with a game plan that's most effective for you? 

From an HR perspective, I don't think it's wise to give specific ("how much") dosing info as everyones tolerance, metabolism etc is different, but I think given its going to be extended pain, that your thoughts about fent combined with another pain med for the synergy may be spot on. The fent patch is long lasting, so while not good for *immediate* post-op pain, this, combined with a decent breakthrough med, should be a big help. 

Im thinking since you've got a supportive surgeon that you can always get more help if what he's giving you isn't getting you where you're comfy? I hope the surgery goes great and the pain is totally covered!

[corlene]

I have surgeries on the regular. If your surgeon has any clue to how Bupe  works they'll get u OFF of it immediately and switch u to a true opiate BEFORE the surgery and deal with the pain appropriately afterwards.

Also if they plan to sedate you with versed and fentanyl it doest sound like it's a very long procedure. And standard dosages to put u down with that are 200 mcg of fent iv and 4 to 10 mg of versed. If ur not put down by that (those dosages wouldn't touch me personally), your going to have general anesthesia.

You need to speak with the crna or anesthesiologist who is putting you under. I've woken up during surgery after being put down with propofol and I can't remember the type of gas based anesthesia they used. All related to my tolerance.

Most people are not going to be put on a fentanyl patch for post op pain regardless of what it is. I had two spinal fusions years ago when I was on bupe(when subs just hit the market)and I was given oxy 30 and after some hustling or the doctor, dilaudid 8

Unless your daily intake is over 120 mg of oxy or 24 of hydromorphone, I highly doubt your gonna get a fentanyl patch.

I don't know of many outpatient surgeries, where your sent home the same day as to what would warrant that. If your pain situation is expected to be that severe u need to have a consult with Pm before u leave the hospital. Your surgeon isn't plying his cards right.

If anyone was having an outpatient procedure the protocol is to get the, off bupe and onto a true opiate before the procedure because post op pain management you'd require far too much, and remember, anesthesia already slows the breathing and heart rate, those nurses aren't going to push heavy amounts of drugs to break thru your bupe. They won't risk their license.

My grandmother had her hip replaced, was in the hospital for 2 days to make sure no severe pain set in, aswell to monitor infection, after that a rehab for a week and than home to follow up with pt. She was given oxy 10s during rehab and pt.

Most surgeries in most people's minds especially ours, sound as its their extremely painful, but in all reality it's not so much.

You need to push for a different angle.

In fact my fent patches say directly on the box: Not to be used for post op pain.

I would not walk into an elective (outpatient) surgery on any type of bupe product regardless of the strength. You'll be fucked.

Good luck!!! I get the most amazing sleep ever from anesthesia, I wake up in pain but shit am I well rested.

[DeadCat (OP)]

Thanks for the replies so far and thanks for any more that may come.

The surgeon and I will talk agaon a few day before surgery. She has already told me she wantes me to taper down to as little as possible (zero being ideal) bope before the surgery and to continue on regualr opiods afterwards  until I switch back too dupe.

If Fentanyl patches aren't used I 'm thining now that I coug et her to give me dilaudid or Opana to replace the bupe for a few days before surgery and for as along as needed afterwards.

Fortunately hte sugeries won't be DEEP just removal of enough scar tissue to close them with sutures as they originally healed "open" and left ugvly "pocket" holes that look like bullet hits. Thus the "twilight" level of anesthesia and outpationt surgery.


It seeems to me that I've just got to hammer home the fact that not only will I need the bupe out of my system to get effective pain manaement but I'll also need something to keep me from going into w/d before and after the procedure. It's even crossed my mind to use it as a way to quit the bupe, just use progressively weaker opiates and not go back to the bupe.

So maybe 2 or 3 days of dilaudid or ER Opana instead of buprenorphine to prevent w/d then an ER opiod with something available for "breakthrough" pain until I am not dealing with the pain but just tolerance. Maybe she'll be kind and toss in some benos to help me rest.

Really, all help is welcome. Surgery is on 11/17.

[Illadelph215]

I wish you luck with the surgery and getting off bupe. Also hoping your transition into another pain killer goes well for you. I wish I had more knowledge for you but the only real experience I have for your situation is being on bupe. You said you have been on it for 12 years, how many mgs are you at now and how many did they start you on? Hope you find what you need and good luck!

[corlene]

@deadcat,

Even methadone would be a good option before the surgery and a more immediate acting opiate after so its easier to transition to bupe after you've recovered.

You mentioned its not going to be deep into the muscle and other viscera, your doctor may have said shes open to help you, but I would get your bupe doc on the ball, as its almost clear to me she doesn't understand the dynamics of bupe. I would certainly have a chat with whoever is giving you the sedation.

I wish you the best, and if you've got any more questions feel free to PM. I know all too much about surgical procedures and pain management. I've had far too many surgeries in the past 18 months. All open procedures too, it blows. What you describe tho seems trivial as to what I have, and will be going through though.

Whatever the case maybe, if she doesn't control your pain well with the first script, call that office at 2am and tell em you cant sleep, etc. And if she doesn't offer to get you off the bupe like yesterday, talk to your bupe doctor and tell him what the deal is, going into surgery with bupe is to be avoided if at all possible.

[Griffin]

If you do get opana as your post op meds make sure that they write for generics. Not only are they cheaper and not abuse proof, they work a lot better and can be used intranasally making them twice as effective. When I was getting them the 20 mg generics were between $350-$600 for 60 of them and the name brand were obviously more expensive. I don't know what insurance you have but you may want to call them just in case to see if you can get it covered because they usually do not cover it.

Good luck with the surgery I hope you recover quickly with as little pain as possible. I would also see if you could switch to a full agonist a week before the surgery so it has time to leave your system. If you can I would taper down as much as possible and then ask to be put on IR oxys or something a week before so the subs have time to get out of your system. That way they won't be blocking your receptors come surgery time.

[Lolleedee]

@deadcat. I hope all goes well with your surgery! I was also wondering what they do when people are on bupe and need pain control.  That was one of the reasons I chose methadone because I was afraid of what would happen in times of acute injury or surgery.

Keep us posted on how you make out!