A patient we have come to know very well is with us again—his third time—for help with a rapid opiate detox. It won’t be as rapid as when he was getting off a gram of heroin a day or when he returned for a detox off Percocet. Each of those out-patient opiate detoxes were done in 3 days.

When Al called us last week, he was bummed. And desperate. He’d managed to go three years with using nothing stronger than over the counter non-steroidals for the occasional back pain he experienced. Al is six foot three and owns a lot of equipment to clear land, remove snow, excavate and haul. His business has grown and he has about twelve full-time employees. His wife has stuck with him through all the ups and downs of his struggles with benzos and opiates, and they have two young children.

About a month ago Al experienced severe tooth pain. Turns out there was an abscess under a wickedly curled wisdom tooth. He needed some pretty serious dental work and needed it sooner than later. 

Al says he felt ok when he woke up after the surgery. The oral surgeon insisted on sending him home with Percocet and Al adamantly refused. The surgeon ‘won’ and Al immediately handed the pills over to his wife to be in charge of doling them out if he really needed them. Turns out he did. And by his own admission, after two doses, he requested the pills from his wife and the whole thing spiraled out of control. Within a week he was buying pills and powder. In an attempt to stop using, he also bought a few Suboxone®.

His urine was positive for opiates, buprenorphine and fentanyl. (The latter was a surprise to him, as it is to many of our patients these days). He’s almost done with the detox and he’ll be fine, but the buprenorphine has extended the detox to a few extra days. Contrast him with Paula.

Paula detoxed with us about five years ago. A lovely, hilarious mother of 2 middle school boys, with a great HR job who drove her “I’m the parent of a scholar”-bumper -stickered mini-van to meet her dealer weekly. She had been using heroin daily for about a year when we met her and she detoxed. She engaged in extensive treatment and came for about a year to receive naltrexone implants. I hadn’t seen her since then until a month ago.

Turns out after a visit with her primary care physician and cardiologist, Paula needed to have heart surgery. Both of those doctors knew her history of substance use and addiction, and they were as nervous as she was to have surgery requiring the use of narcotic pain medications after her operation. She scheduled a pre-op visit with us to discuss her options.

The reality is that many of our detox patients will have to face having surgery someday. By creating a plan and informing all of her doctors about her history, Paula was able to use her pain medication for the minimal amount of time. Together we decided to put her on naltrexone for a few weeks after she no longer needed the pain meds.

People with Substance Use Disorder who need surgery may find it useful to get all their providers on board and discuss a plan for pain control. While it still may be difficult to come off the pain medications, the support of medical professionals who can monitor a realistic taper can make all the difference in a patient’s remaining in recovery.

Joan Shepherd, FNP