ASA Monitor 11 2018, Vol.82, 52-55.
A 48-year-old man with a history of severe depression, former heroin use and chronic low back pain presents for elective minor scar revision surgery. He is taking 8 mg of buprenorphine sublingually daily, and a recent urine screen was negative for illicit substances. Which of the following is the best course of action for his buprenorphine use perioperatively?
- (A) Discontinue buprenorphine and offer regional anesthetic techniques.
- (B) Increase buprenorphine to 16 mg/d for postoperative pain.
- (C) Continue buprenorphine and give adjunct nonopioid medications.
- (D) Discontinue buprenorphine and convert to short-acting opioids.
Buprenorphine has emerged as a new therapy for chronic pain, addiction and opioid use disorder. It may be marketed as Suboxone®, Zubsolv® or Bunavail®, which are a combination of buprenorphine and naloxone. Buprenorphine has several unique properties that potentially make it safer than other types of opioids. It is 30 times more potent than morphine, has a long and variable half-life and has a ceiling effect for respiratory depression. There is evidence to show that buprenorphine can decrease chronic pain, opioid-induced hyperalgesia, depression, opioid cravings and relapse. Buprenorphine competes with other opioids for the opioid receptor, which may make the use of perioperative supplemental opioids problematic in a patient with long-term buprenorphine use.
A recent article analyzed the issues inherent in patients presenting for surgery who are on buprenorphine therapy. There is currently no consensus on optimal acute pain management in these patients. The authors reviewed published reports of perioperative analgesic strategies for patients taking buprenorphine who present for either elective or emergent and urgent surgery. There is evidence that buprenorphine is effective in treating pain, depression and opioid-induced hyperalgesia so it may be advantageous to continue it perioperatively. In addition, discontinuation can place the patient at risk for opioid relapse, especially in the stressful perioperative period. Furthermore, discontinuing buprenorphine may cause withdrawal symptoms or worsening of depression. Therefore, the recommendation for elective surgery with minimal or no expected postoperative pain is to continue buprenorphine at the current dose with the addition of adjunct nonopioid therapies (Figure 1). If the buprenorphine was discontinued 24 to 72 hours preoperatively, then the recommendation is to treat the patient with supplemental opioids. For elective surgeries with expected moderate to severe postoperative pain, consideration should be given to canceling or postponing surgery until the patient can wean off the buprenorphine and begin taking short-acting opioids. If the patient is off buprenorphine, then adjunct medications including short-acting opioids can be used.
Conversely, if a patient presents for emergent or urgent surgery, then time will determine the involvement of the prescribing clinician in assisting with the perioperative plan for pain control (Figure 2). If there is minimal or no postoperative pain expected from the surgery, then buprenorphine can be continued with nonopioid-based adjunct medications. If the patient is off buprenorphine for five or more days, then short-acting and traditional opioids can be used. If the urgent surgery has the potential for moderate to severe post-operative pain, then buprenorphine should be discontinued and replaced with patient-controlled analgesia with opioids, intensive-care level of monitoring and nonopioid-based adjuncts including regional anesthesia. Clinicians can expect higher amounts of short-acting or traditional opioids to be required in patients when replacing buprenorphine, similar to doses for opioid-tolerant patients.
The authors note the paucity of data in developing guidelines for the perioperative treatment of patients on buprenorphine. However, when possible, adjunct nonopioid-based medications and regional anesthetic techniques should be used in managing acute postoperative pain. Patients using buprenorphine will likely require higher doses of opioids. Planning with the prescribing clinician, the surgical team and the patient are key recommendations in the setting of buprenorphine use.
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