Where Do We Stand on “Higher Dose”?

Hey there 👋🏻

I did a survey last week to answer this very question: where do we stand on “higher dose” when Suboxone is involved in the perioperative setting? Help me get to 300 votes if you haven’t voted 😉 (And I plan to keep asking throughout the year until people really start thinking about this).

If you’re new to Suboxone management, one of the most common questions I get is:

“Can you help me dose the opioid post-op because the patient is on Suboxone?”

This question is valid because Suboxone is being prescribed more often, and there have been so many changes in its management over just the last 15 years. If you look at the research, you’ll see this line a lot:

Fernando RJ, Graulein D, Hamzi RI, Augoustides JG, Khalil S, Sanders J, Sibai N, Hong TS, Kiwakyou LM, Brodt JL. Buprenorphine and cardiac surgery: navigating the challenges of pain management. J Cardiothorac Vasc Anesth. 2022;36(9):3701-3708. doi:10.1053/j.jvca.2022.04.050

Yes, exactly! Higher opioid dose.

Here’s why it gets confusing:

• There are multiple opioid conversion tables out there, and we don’t all use the same one.

• What really counts as a “higher” opioid dose? Where do we draw the line between low, medium, and "higher"?

So, let’s switch perspectives and ask an easier question:

What do we consider a starter dose?

Think hydrocodone 5 mg every 4–6 hours as needed, or oxycodone 5 mg every 4–6 hours as needed. Both are commonly cited in drug references.

I’ve personally seen patients who only need starter doses post-op while on Suboxone, so not every patient needs a higher dose. But the overall consensus is to anticipate higher opioid requirements.

So until we see more results, let’s agree not to rely on starter opioid doses if a patient is on Suboxone above 16 mg post-op.

See you next time,

SP