Should Suboxone Be Held While Taking Vicodin After Surgery?
No, the patient should continue their Suboxone (buprenorphine-naloxone) at their baseline dose throughout the perioperative period and not hold it while taking Vicodin (hydrocodone/acetaminophen) for postoperative pain. 1, 2
Primary Recommendation: Continue Buprenorphine
It is almost always appropriate to continue buprenorphine at the preoperative dose, and it is rarely appropriate to reduce or stop the buprenorphine dose. 1 This recommendation is based on expert consensus from the Perioperative Pain and Addiction Interdisciplinary Network (PAIN) published in the British Journal of Anaesthesia. 1
Why Continuation Is Critical
Stopping buprenorphine precipitates withdrawal symptoms and dramatically increases relapse risk in patients with opioid use disorder, which carries significant morbidity and mortality consequences. 1, 2
Recent high-quality evidence from a 2025 national Veterans Affairs cohort study (1,881 surgical procedures) demonstrated that patients who continued buprenorphine had lower pain scores and required less supplemental opioids compared to those who interrupted it (39.7 mg vs 74.2 mg morphine equivalents/day, P < 0.001). 3
Discontinuation hinders harm reduction and treatment retention for addiction, which is a life-threatening condition with mortality implications. 1
Pain Management Strategy: Layered Approach
Foundation: Continue Baseline Buprenorphine
Maintain the patient's current Suboxone dose unchanged throughout the perioperative period. 1, 2
Consider dividing the daily dose to every 6-8 hours rather than once daily to provide more consistent analgesic coverage, as buprenorphine has analgesic properties at these divided intervals. 2, 4
Layer 1: Aggressive Multimodal Non-Opioid Analgesia
Scheduled acetaminophen 1000 mg every 6-8 hours (already present in Vicodin, but ensure total daily acetaminophen does not exceed 4000 mg from all sources). 2, 4
NSAIDs or COX-2 inhibitors if no contraindications exist (renal dysfunction, cardiovascular disease, bleeding risk). 2, 4
Regional anesthesia techniques, nerve blocks, or local anesthetic infiltration should be maximized when anatomically appropriate. 1, 2
Adjunctive medications such as ketamine, gabapentin/pregabalin, or dexmedetomidine can reduce opioid requirements. 1, 2
Layer 2: Full Mu-Opioid Agonists for Breakthrough Pain
Hydrocodone (Vicodin) can be added ON TOP OF continued buprenorphine for breakthrough pain, but expect to need higher-than-normal doses. 2, 5, 6
Patients on buprenorphine require 2-4 times typical opioid doses due to buprenorphine's high receptor affinity and partial agonist activity creating competitive receptor blockade. 2, 5
A 2019 case series demonstrated that patients continuing buprenorphine perioperatively required substantial supplemental opioids (median 100-199 mg IV morphine equivalents in 24 hours), but this approach was feasible and safe. 6
Critical Pharmacologic Considerations
Buprenorphine's Unique Properties
Buprenorphine is a partial mu-opioid agonist with extremely high receptor affinity, meaning it binds tightly to opioid receptors but produces less maximal effect than full agonists. 5
Full agonists like hydrocodone do not readily displace buprenorphine from receptors at standard doses, which is why higher doses of Vicodin may be needed. 5
Buprenorphine has an extended duration of action (24-72 hours), prolonging these competitive effects. 5
Why Holding Buprenorphine Doesn't Help
The 2025 VA study definitively showed that interrupting buprenorphine resulted in WORSE outcomes: higher pain scores (5.5 vs 4.9) and nearly double the supplemental opioid requirements (74.2 mg vs 39.7 mg morphine equivalents/day). 3
Physical dependence on buprenorphine develops after regular use, and abrupt discontinuation leads to withdrawal symptoms within 24-72 hours. 7
Withdrawal symptoms include lacrimation, rhinorrhea, piloerection, restlessness, dilated pupils, tachycardia, and severe dysphoria, which compound postoperative pain and suffering. 8
Practical Algorithm
Continue baseline Suboxone dose unchanged (or divide into 6-8 hour dosing for better analgesia). 1, 2
Implement aggressive multimodal non-opioid analgesia as described above. 2, 4
Add Vicodin for breakthrough pain at standard starting doses, but be prepared to escalate. 2, 6
If pain remains inadequately controlled, increase Vicodin dose by 50-100% or switch to a more potent opioid like oxycodone or morphine at 2-4 times typical doses. 2, 5
Monitor closely for respiratory depression when combining buprenorphine with full agonists, though the partial agonist properties of buprenorphine may provide a "ceiling effect" for respiratory depression. 5
Coordinate with the patient's buprenorphine prescriber for postoperative follow-up to ensure continuation of addiction treatment. 2, 4
Common Pitfalls to Avoid
Do not abruptly discontinue buprenorphine thinking it will "make room" for Vicodin to work—this causes withdrawal and increases relapse risk without improving analgesia. 1, 3
Do not underdose supplemental opioids out of fear—patients on buprenorphine genuinely require higher doses, and undertreated pain increases suffering and relapse risk. 2, 6
Do not exceed 4000 mg total daily acetaminophen when combining Suboxone with Vicodin and other acetaminophen-containing products, as hepatotoxicity risk increases. 7
Do not prescribe excessive quantities of Vicodin for discharge—limit to 15-20 tablets with explicit instructions for time-limited breakthrough use only, as patients with opioid use disorder remain at risk for relapse. 4