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Substitute Drugs for Surgery for Addicts
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Substitute Drugs for Surgery for Addicts

Dear Dr. Steve,

What are the things an opiate addict should be telling the doctor or oral surgeon if surgery is needed ? What substitutes should be used for the anesthesia and also prescribed for the next few days of pain? My daughter must have her wisdom teeth removed after she comes home from rehab and I am worried sick. How about other more major surgeries later on ?
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Avatar_n_tn
I know you posted for Dr. Steve, but in case you don't get a timely answer, I have some experience with your daughter's situation.  My addiction doctor prescribes if and when I need pain meds.  The drug of choice is Buprenex (buprenorphine) for the reasons you already know.  If something else is necessary, since addicts have a higher tolerance for pain meds, the idea is to prescribe at twice the normal dosage, for half the usual amount of time.  For example, 2 percocet every six hours, rather than one.  Also, it is important that YOU control the meds and not your daughter.  Finally, any narcotic meds will start the cravings again after they are gone--an unfortunate result.  Hope this is helpful.
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Avatar_n_tn
Hi Brian..

This is curious to me.. if buprenex is available then why the bother with double doses of regular narcotics ??.. e.g. your example of percocet. Also, I know nothing about anesthesia.. are narcotics used there too ??? I am curious to know if there are substitutes in that area also. I heard once that in the presence of pain the brain releases a chemical known as TIQ (?) and thus the narcotics will only affect the pain and not the pleasure center of the brain. I suppose it sounded like the brain "knows" the difference between opiates for pain and pleasure. I am wondering if anyone knows anything about this and if it is a myth. Afterall I am reading about all these people here who got addicted because they were in pain and used prescribed narcotics. I hope you or someone can comment.
Best wishes, Brighty
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Avatar_n_tn
The problem with the Buprenex is that it is only available as of now in injection form (or can be made into troches for dissolving under the tongue).  Because of that, many doctors don't want to prescribe it and many patients don't want to inject themselves.  Narcotics are used sometimes with anesthesia, although not usually for wisdom teeth.  The anesthesia itself is non-narcotic.  For a major surgery they usually premedicate with narcotics.  With respect to the brain releasing chemicals in response to pain, although I have read about this I don't think it affects the way the addict's brain will respond to painkillers.  From everything I have read and heard, once someone has become addicted to painkillers, they will inevitably become addicted again if painkillers are prescribed for more than a very short period of time, regardless of whether they have actual pain.  Apparently the brain chemistry is permanently changed.
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Avatar_n_tn
I work as an addictive disease counselor and have to address this issue with my patients/clients on a regular basis. First of all, I am NOT a physician, but I have regular consultation about CD treatment issues with Addiction Psychiatry and Addiction Medicine physicians, Nurses with CD treatment experience, and pharmacists who have knowledge of CD issues. What I have been told is that for post-surgical pain there is no substitution for Narcotic Analgesics, unfortunately. I have been told that to adequately control the pain one must make use of these highly addictive drugs in the short-term. And that's the key, the drugs are used short-term and carefully monitored and managed. Vigilant medical oversight is essential! As soon as the addict patient is able, they should be transitioned off the Narcotic pain-killers to non-narcotic medications. The non-narcotic pain relievers could include the NSAID (Non-Steroidal Anti-Inflammatory Drug) class of meds (such as DayPro, Lodine, Voltaren, Motrin, or Ibuprofen)or Acetaminophen. These meds will not give as potent pain-relief as the Narcotic Analgesics, but they will reduce the underlying inflammation and swelling and will provide some pain-relief. This mode of pharmacological intervention is what I have been told is most effective and safest for the addict patient in acute pain. For chronic pain, the Addiction Psychiatrist I work with usually goes in with a combination Votaren & Depakote, or Voltaren & Neurontin. For our patients suffering from chronic arthritic conditions, we have seen these combinations work well and they are non-addictive alternatives. Of course, there are risks for the patient taking NSAIDs and other meds, but it's the Doc's job to weigh the pros and cons before deciding on a course of action. Anyway, the above is just what I have learned about pharmacologic pain-management in the addicted patient from my experience in the field. No doubt, I have more to learn, but hope this helps. Always consult with the physician, preferably and Addiction Medicine specialist, that's what they get paid for.  Sincerely, Geoff.
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Avatar_n_tn
When I got my wisdom teeth out I took ibuprofin, why not just request something in the anti-inflammatory line? Personally I find it works better for pain anyway. Lodine is one of my favorites, no side effects (except on stomache for some), no drug effects & certainly not addictive.
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Avatar_n_tn
Thank you for a very informative reply which is really helpful to us. I am wondering what action Depakote has in pain relief.  I have only heard of it for mood swings. Best wishes, Brighty
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Avatar_n_tn
Yes, there were too many incidents of patients on DayPro testing positive for Benzodiazepine. These were people who never used Benzos and who were kept in a controlled inpatient environment. Something about them and the DayPro made for a false positive UDS indicating presence of Benzodiazepine. Very interesting, but in some cases we have seen patients taking Wellbutrin drop a false positive for Amphetamine. We continue to use Wellbutrin- another good drug. I've really seen it help with impulse control and concentration in the ADHD addict patient. Also, there is anecdotal information that Wellbutrin may help ease cocaine craving. Afterall, it is FDA approved for smoking cessation...
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Avatar_n_tn
I don't have the answer as to why this combination Depakote and Voltaren often seems to work, but I'll take a guess since I don't think even the Addiction Psychiatrist I work with actually knows why it works. It must have something to do with Depakote (and other anticonvulsants) anxiolytic properties. If a drug can help to ease the anxiety that is often associated with the pain, then the addict patient can be more relaxed which in turn may translate to some pain relief. But, I suspect there is even more at work here with this combination of meds than we currently understand. By the way, my Doc likes "DayPro" (another NSAID class drug like Voltaren) and believes it is a good drug to use with addicts with pain issues, however he won't use it any longer in our program because there were too many false positive UDSs of people who were being prescribed the DayPro. I'll describe this in more detail in a post above. Cheers, Geoff.
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Avatar_n_tn
Thank you both for information that is truly helpful. Best wishes, Brighty
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Avatar_n_tn
Thanks for the information:-) In reference to the comments above, what about Wellbutrin for opiate (heroin specifically)cravings ? Or are dopamine cravings different from opiate cravings ? And do you mean the slow release wellbutrin ? And also since depakote is an anticonvulsant, can it safely be used with wellbutrin to prevent seizures ? Also, what exactly is neurotin ? Sorry for all the questions.... and thanks for the answers! Brighty.
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Avatar_n_tn
I haven't heard anything about Wellbutrin for Opioid Addiction or Opiate craving.

I have seen Depakote and Wellbutrin prescribed together for patients, particularly for the Bipolar spectrum disorders. The Depakote probably makes it less likely that someone would suffer a seizure when taking the Wellbutrin at the same time. I'm not sure if or how the Depakote would affect the blood levels of the Wellbutrin. I've heard that Tegretol and Wellbutrin are generally not prescribed together because Tegretol will drop the Wellbutrin level to zero - essentially eliminating it from the person's system!

Neurontin is an anti-convulsant medication in the same class of meds as Depakote, Tegretol, Lamictal, Topamax, etc. There are anecdotal reports of Neutontin being effective for treatment of Bipolar Disorder, however there are no controlled studies demonstrating this! Nevertheless, some physicians are prescribing it to person's with Bipolar Disorder. Evidence seems to suggest that this medication can help with Impulse Control,with Anxiety symptoms, and with Pain Management. The Addiction Psychiatrists I work with use Neurontin in this way. They use it in patients with impulse control problems and anxiety, and those suffering from chronic pain syndrome (often in conjunction with an NSAID class medication). By the way, Depakote is a medication with a solid reputation as a mood-stabilizer and effective impulse-control agent.

Some of your questions sound good for the Doc to comment on.

Regards, Geoff.
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