Traditional narcotics will have decreased analgesic effects on patients who are taking a newer drug for opioid addiction treatment called Suboxone. Here's what your surgeons, staff and anesthesia providers need to know about Suboxone (buprenorphine with naloxone).

Staying put on the narcotic ladder
Suboxone's active ingredient, buprenorphine, is a mixed narcotic agonist/antagonist. Imagine a "narcotic ladder" showing the 10 steps of analgesia: Step 0 is a patient with little or no narcotics in his system and 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 level fall, they begin to experience withdrawal once they fall below Step 3. This withdrawal syndrome is profound, producing sweats, cramps, diarrhea, agitation and mood changes.

When the narcotic-addicted patient takes a Suboxone tablet, sublingual, the medication places the individual on Step 3 of the ladder and holds him firmly there. Remaining at Step 3 prevents withdrawal symptoms and stops craving in the vast majority of patients. The typical dose of Suboxone is between one and three tablets daily. The drug has a peak ceiling effect, meaning if the patient takes more than three pills daily, he won't go higher on the ladder than Step 3. This ceiling effect is one of the great advantages of Suboxone, deterring its abuse potential. The naloxone in Suboxone is not bioavailable sublingually; it's placed there to deter inappropriate use of the medication.

Suboxone has a high affinity for the opiate receptor. Therefore, if a patient takes a narcotic, such as Percocet, while on Suboxone, he won't move up to Step 4 of the narcotic ladder, but will instead remain at Step 3. Suboxone will provide some analgesia and euphoria, but its primary indication is for the treatment of narcotic addiction. Suboxone can be displaced by higher doses of narcotics.

Managing patients taking Suboxone
There's no gold standard for treating patients taking Suboxone before elective surgery, and your staff is likely to have several questions about how to manage these patients perioperatively. For example, what should they do if the patient complains of pain in the recovery room? Will post-operative pain medications work? Will they re-trigger the patient's addiction? Careful titration of perioperative narcotics with appropriate monitoring for significant side effects remains the mainstay of treatment. Although you should individualize care for the narcotic-addicted patient, we can apply some general statements to most of these patients.

• Pre-op. Stopping Suboxone two to three days before elective surgery lets Suboxone levels fall and traditional opiates be more effective. You may occasionally receive calls from patients either in pain or, more frequently, beginning to experience withdrawal symptoms when they've stopped taking Suboxone in anticipation of elective surgery. In these cases, a physician should see the patient, along with a support person, immediately and prescribe short-acting narcotics (Percocet 5/325, # 10, one poq4h prn) to ward off withdrawal for a couple days.
• In the OR. Your anesthesia team should know that the patient on the table is on Suboxone. Anesthesia providers are skilled at using anesthetic techniques (such as inhalational agents) and at carefully titrating narcotics to effect. The use of various regional anesthetic techniques, including simple field blocks, can help greatly in the management of these patients. You may also consider using non-narcotic analgesics where indicated.
• PACU. Feel free to give patients on Suboxone traditional narcotics in the recovery room when they experience pain. Understanding the pharmacology of Suboxone lets you titrate post-op narcotics gently and appropriately. Staff should diligently monitor respiratory rate while titrating in post-op narcotics in the recovery room; respiratory depression is the principle side effect that merits extreme vigilance.
• Post-op. There's no consensus regarding the discharge of patients on Suboxone. One thing to consider is the risk of restarting the patient's narcotic addiction problem. Surgeons should treat these patients as they'd treat a standard patient, with one exception: It is incredibly helpful if they have strong support people to help monitor their pain medications in the immediate post-operative period. Patients should be transitioned back to their Suboxone around the time the surgeon would normally move patients off their post-op narcotics. Remind these patients that they need to be on Step 3 of the narcotic ladder when they restart Suboxone to avoid withdrawal symptoms. You should also strongly encourage them to resume active counseling for their addiction.