Pain Management on Buprenorphine

I had a bit of writer’s block this week. I was pondering what topic I should tackle next on my blog. Then I got a phone call from a dentist’s nurse, and voila, problem solved.

I’m going to change the name and description of my patient to protect her identity.   “Sally” has been doing great the entire six months she’s been my patient. Sally was ready for recovery. Over the last ten years, she’s been to multiple inpatient programs, for up to three months at a time, for treatment of her opioid addiction. She had achieved some time in abstinent recovery, ranging from a few weeks up to nine months, but relapsed because she never felt normal off all opioids. She continued to have low-grade nausea, fatigue, and felt achy most days. When she saw me last summer, she’d been in a terrible relapse for around eight months, and had been injecting the opioid pills prescribed by a local pain clinic. Her husband was supportive, and appropriately worried Sally was going to die of an overdose.

Sally wanted to start Suboxone, but wasn’t expecting much from it. She’d investigated Suboxone on the internet, and thought her opioid tolerance was too high for this medication to work. However, but she wanted to try every option before entering a methadone treatment center. I also suspected Suboxone wouldn’t be strong enough, but agreed with her that it would be worth a try.

She felt normal within the first week. We started with 4mg on the first day, and then went to 8mg on day two. When we went to 16mg on day three, Sally was amazed and relieved that she felt back to normal. She didn’t feel high and she didn’t feel in withdrawal.

She hasn’t looked back since. Every urine drug screen, done nearly every visit, has been positive only for Suboxone. She goes to 12-step meetings, has a sponsor, and does service work at her home group. She’s relatively happy, though she still takes an anti-depressant to prevent a relapse of her depression, which has been severe in the past.

Anyway, I say all of this to point out how well she’s doing. She’s also getting her physical health concerns addressed, and started seeing a dentist to get her teeth fixed. She had neglected them during active addiction, and needed a great deal of work done. She opted for dental implants.

At her last visit, we discussed pain management after her procedure. The pain from many dental procedures can sometimes be managed with anti-inflammatories, but I knew dental implants were more complicated.  I told Sally I’d like to talk with the doctor who will be managing her post-operative pain. I wrote down my cell number for Sally to give to her doctor, rather than my office number, to allow her dentist to get in contact with me more easily. I told Sally to stop her Suboxone 36 hours pre-procedure, so that her opioid receptors wouldn’t be so blocked that short-acting opioids would be ineffective. We planned for her husband to hold the bottle of pain pills, and dispense as directed by her oral surgeon. I instructed her how to make the change back to Suboxone once she no longer needed pain medication. I planned to see Sally one week after the procedure, so I could make sure she was OK, and back on Suboxone.

I heard nothing until this morning. I got a call on my cell phone from Dr. “X’s” nurse. She said Dr. X had just finished the procedure, but didn’t feel comfortable prescribing opioids for an addict. Dr. X preferred for me to handle her post-operative pain.

I felt my temper flare immediately. “Gee, I wish your doctor had called me before the procedure so we could talk about this. Since I don’t do oral surgery, I don’t know how much pain patients usually experience. Surgeons usually manage their own patients after surgery. What does Dr. X usually prescribe for patients after this procedure?”

“Thirty pills of oxycodone 10mg. But the doctor wasn’t comfortable giving that many. He’s willing to give her only 15 pills.”

“You know, I gave her my cell number so your doctor could call me before the procedure. It’s better to decide all of this prior to the surgery, don’t you agree?”

“We don’t have time to call everyone.”

“But you called me today.” I felt a familiar twitch in my right eyelid. “Look, it’s OK for him to prescribe what he usually prescribes. After all, she will have as much pain as any other patient. In fact, because of her opioid tolerance, she may need a bit more than an average patient. We’ve talked to her husband and he’s going to hold the pill bott…”

She interrupted me, saying, “The doctor doesn’t want to get into some big deal, writing for a bunch of pain pills for an addict. The doctor wants you to take over prescribing for pain.”

“I know he does…” it came out as an evil splutter because I was thinking about how much Sally was probably paying this guy, who should have told her in advance that he wasn’t going to prescribe post-op pain medication. I know dental implants are not cheap and probably not covered by insurance. And I suspected this dentist, to whom she was likely paying a big pile of money, looked down on Sally because of her history of addiction. I felt anger.

“You know,” I said, spittle gathering at a corner of my mouth, “You know, it isn’t ethical to withhold pain medication if you do a procedure that causes pain.  I can understand he doesn’t want to write large amounts for an extended time, but we’re talking about an acute pain situation that will last what, about a week? He knows that better than me. He needs to prescribe what he usually does to any other patient. We’ve already talked to Sally about precautions to prevent a relapse.”

The dilemma was solved because apparently, a doctor was listening to our conversation at the nurse’s elbow. He indicated to the nurse that he would be willing to prescribe the usual amount. I was miffed that the doctor didn’t talk to me himself, but he may not have been the one who did Sally’s procedure. At any rate, that was what I wanted anyway, so I tried to be helpful and give them information for future use.

“You can call me any time about patients with both pain and addiction. It’s more complicated to treat them, but with proper safeguards it can be done without too much trouble…”

“Ok thanks. Thanks for talking to us.”

At that point it sounded like the nurse would rather get on with her work day than listen to me try to explain how addiction is a medical problem that can be managed just like any other chronic disease.

I was angry because the dentist didn’t call me before the procedure, and because he wasn’t honest with the patient. He neglected to tell her about his plans to write for less than usual the amount of pain medication. I was sad because I suspected that he looked down on this nice lady her because of her history of addiction…but not so much that he wouldn’t take her money for fixing her teeth.

It’s a shame, because that dentist could have learned something from Sally, like how she’s a funny, warm person who has courageously overcome a devastating and life-threatening illness.

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6 responses to this post.

  1. Posted by Tonya Roberts on February 17, 2012 at 2:36 am

    Ok….. Just a few more questions I promise. Do you assume that new patients coming into treatment are telling the truth about their past and current use? Do you base starting dose soley on their information? Is a complete drug screen required before initiating first dose?

    Thanks again.

    Reply

    • When seeing new patients, I say “Believe, but verify.”
      Most of the people seeking addiction treatment are desparate for help, but occasionally because of fear that they won’t get enough methadone or buprenorphine to get rid of withdrawal, they exaggerate their tolerance. That’s why patient history is only one portion of the information gathered at admission. I always do a rapid drug screen on all patients as part of the admission process. Of course, drug screens aren’t 100% either, and some opioids need special tests because they won’t show on a test for opiates. An extended opioid panel is needed for methadone, buprenorphine, opioids, and opiates. At one of the opioid treatment centers where I work, they use an even more extensive opioid screen. I like that, but it adds to their costs.
      I also use physical exam, and check new patients on the prescription monitoring program, which I believe should be the standard of care. Most patients entering opioid addiction treatment in my neck of the woods are using prescription opioids, many getting prescriptions from multiple doctors. Those bridges have to be burned at admission, or may become relapse triggers later.
      Sadly, we don’t have a nationwide prescription monitoring database, though some really smart people in the government are working on that. I work about 30 miles from a bordering state that only allows doctors licensed in their state to have access to their prescription monitoring database, so I don’t have access to it. I’m certainly not going to go through the time and expense of getting a license in that state only to see their database. Hopefully that will change soon.

      Reply

  2. Awesome article/subject!!! I so wish all doctors w/a license to prescribe meds would read this article. Furthermore, i think it should be a requirement that they teach some sort of class on this in medical school. Being in treatment myself my biggest fear is having to go to the ER & I actually have to tell them that i take methadone! We desperately need more doctors like Dr.Burson!

    Reply

  3. I really appreciate this article. I went in to an oral surgeons office today and was honest about being on SUBOXONE. To the surgeons credit she did call my sub provider but unfortunately for me – HE doesn’t seem to understand how this medication works. He told the surgeon I should be fine if I stopped taking my sub 24hrs prior to the surgery and that Vicodin for 3 days would be all Id need for the post op pain. Long story short, I left her office today…without having 2 molars removed. I’ve been clean for over 4 yrs, go to mtgs weekly, have a sponsor and therapist. I’ve held my current job for 4 yrs as a nurse and have given well over 250 random ua’s in those 4 yrs. I had a tooth pulled last year after following the 24 hrs off sub as advised per provider, the surgeon prescribed Percocet then and my pain was absolutely horrific. I’ve sched with a different surgeon and am planning on talking with them ahead of time. I’ve never walked out of an appointment like that before but I cannot imagine going through another ordeal like last time – with LESS meds. My husband also keeps the meds for me. This surgeon today was so hyper focused on me taking sub and quite determined to let me know I had zero say in my pain management. I will be writing a letter to that clinic and the board of dentistry. Thanks again!

    Reply

  4. Posted by Willy Perez on February 2, 2013 at 6:20 pm

    Wow this blog is magnificent i like studying your posts. Stay up the good work! You already know, many individuals are searching around for this information, you can help them greatly.

    Dr. Carl Balog

    Reply

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