A comprehensive, multimodal pain strategy is the cornerstone of policy formation for managing buprenorphine perioperatively at Stanford University Medical Center.
As awareness of the pervasiveness of the opioid epidemic increases, clinicians have begun to take steps to do what they can to control it. “We are having more and more patients coming for surgery that are on the drug buprenorphine,” said principal investigator Anuj Aggarwal, MD, an anesthesia resident at Stanford University Medical Center, in California. “However, there is not a comprehensive strategy or literature to guide anesthesiologists in the management of these patients.”
At Stanford, patients usually were taken off buprenorphine before surgery in an attempt to control pain better postoperatively. “But patients were not being followed up and their buprenorphine was not being continued after surgery,” Dr. Aggarwal said.
As a result, following discharge, patients were at risk for difficulty resuming maintenance therapy for opioid addiction. “As a specialty, we needed to start considering the entire perioperative period, including after being discharged from the hospital,” he said.
To formulate policy, the investigators reviewed the charts of approximately 50 patients, most of whom were prescribed buprenorphine for chronic pain. All patients were admitted to Stanford University Medical Center for surgery between January 2013 and June 2016, with patients about evenly split between those who were weaned off the opioid before surgery and those who continued on the drug through the postoperative period.
“The fear that we would not be able to adequately control pain if the patient was still on buprenorphine did not really pan out,” Dr. Aggarwal said of the study, which was presented at the 2017 annual meeting of the American Academy of Pain Medicine. “Patients who were kept on buprenorphine were more successfully discharged on buprenorphine.”
Another surprise of the chart review was that patients who had buprenorphine discontinued before surgery “consumed significantly greater amounts of opioid in the immediate postoperative period, yet the pain scores for the two groups were not all that different,” he noted.
The investigators also were astonished by the lack of coordination of care between the preoperative and discharge services for these patients. “This put them at high risk for adverse events and for not having their buprenorphine properly managed,” Dr. Aggarwal said.
Based on data gleaned from the reviewed charts, the investigators formulated a policy for preoperative buprenorphine management, which entailed coordinating with the various service lines at Stanford, so nearly all patients could continue the drug before surgery and through the immediate postoperative period.
“We also ensure that patients have a more comprehensive plan preoperatively for their pain management immediately after their surgery,” Dr. Aggarwal said. “In addition, we have a plan already in place for their discharge, even before they come for surgery.”
Furthermore, the comprehensive, multimodal pain strategy allows the acute pain service to assist the surgical services in discharge planning.
For instance, if a patient is on low-dose buprenorphine (2 mg/day) for a history of chronic pain and perhaps a history of opioid dependence, the patient is informed in the preoperative clinic that he should continue taking buprenorphine through the preoperative period. In addition, the preoperative clinic coordinates with the buprenorphine prescriber, so the patient can meet with the prescriber immediately after surgery to follow-up with pain management.
When the patient arrives at the hospital on the day of surgery, “the plan is already in place,” Dr. Aggarwal said. On the day of surgery, the anesthesiologist can review the preoperative assessment and start multimodal pain management during surgery. The PACU is kept in the loop as well.
The policy at Stanford University Medical Center was officially launched in April 2017. The important targets for staff education are informing nurses and advanced practitioners in the preoperative clinic about the policy and its rationale. “We are also holding lectures and educating our anesthesiology residents and attendings about the policy,” Dr. Aggarwal said.
A future goal is to educate the most common surgical service lines that interact with these patients. “Coordination of services and providers is really important because different services have very different priorities,” Dr. Aggarwal said. “Because each priority is valuable, the global care of the patient can at times become adrift. For example, with buprenorphine, the immediate concern during surgery and right after surgery is to help manage the patient’s acute pain. However, the global notion of the patient needing this drug for the management of their opioid dependence and chronic pain can easily be lost, as can what happens to the patient once they are discharged.”
By coordinating services, “everyone can be on the same page to ensure that the patient receives the best care possible,” Dr. Aggarwal said.