The opioid epidemic has resulted in increased opioid‐related critical care admissions, presenting challenges in acute pain management. Limited guidance exists in the management of critically ill patients with opioid use disorder (OUD). This narrative review provides the intensive care unit clinician with guidance and treatment options, including nonopioid analgesia, for patients receiving medications for OUD and for patients actively misusing opioids. Verification and continuation of the patient's outpatient medications for OUD regimen, specifically buprenorphine and methadone formulations; assessment of pain and opioid withdrawal; and treatment of acute pain with nonopioid analgesia, nonpharmacologic strategies, and short‐acting opioids as needed, are all essential to adequate management of acute pain in patients with OUD. A multidisciplinary approach to treatment and discharge planning in patients with OUD may be beneficial to engage patients with OUD early in their hospital stay to prevent withdrawal, stabilize their OUD, and reduce the risk of unplanned discharge and other associated morbidity.

Background Neuromuscular blockade (NMB) is thought to improve operative conditions during certain procedures. Published descriptions of minimally invasive hip replacement techniques specify the need for "excellent relaxation", however, the optimal degree of NMB required for such cases has not been studied. We performed a randomized, single-blind study comparing the effect of moderate and deep neuromuscular blockade on surgical conditions and operating time during minimally invasive anterolateral hip replacement. Vecuronium was administered to maintain moderate NMB (train-of-four count of 1-2) or deep NMB (train-of-four count of 0, post-tetanic count of 1-2). Methods In this study, 116 patients were randomized to receive moderate or deep neuromuscular blockade; depth of blockade was monitored using acceleromyography. The primary outcome was the number of requests from the surgeon for additional blockade intraoperatively. Secondary outcomes included operative times and assessment of the operative conditions by the surgeon utilizing the Leiden-Surgical Rating Scale. Results Cases with additional requests for blockade did not differ between the deep and moderate NMB groups (11/58, 19.0% vs 8/58, 13.8%); relative risk, 1.22 (95% CI [confidence interval], 0.70-2.15), p=0.62. Neither time from incision to prosthesis reduction (33.8±1.2 min vs. 32.6 ±1.2 min; difference in geometric mean, 0.96 [95% CI, 0.90-1.04] minutes, p=0.33), nor the surgeon's assessment of operative conditions (p=0.88), differed between the deep or moderate NMB groups, respectively. Conclusions Deep NMB did not produce significantly improved operative conditions compared with moderate NMB. Routine use of deep NMB during minimally invasive anterolateral hip arthroplasty is not supported by this study.

The number of patients maintained on buprenorphine is steadily increasing. To date, no study has reported buprenorphine management practices for these patients during critical illness, nor its relationship with supplemental full‐agonist opioid administration during their hospital stay. In this single‐center retrospective study, we have explored the incidence of buprenorphine continuation during critical illness among patients receiving buprenorphine for the treatment of opioid use disorder. Additionally, we investigated the relationship between nonbuprenorphine opioid exposure and buprenorphine administration during the intensive care unit (ICU) and post‐ICU phases of care. Our study included adults maintained on buprenorphine for opioid use disorder admitted to the ICU between December 1, 2014, and May 31, 2019. Nonbuprenorphine, full agonist opioid doses were converted to fentanyl equivalents (FEs). Fifty‐one (44%) patients received buprenorphine during the ICU phase of care, with an average dose of 8 (8–12) mg/day. During the post‐ICU phase of care, 68 (62%) received buprenorphine, with an average dose of 10 (7–14) mg/day. Lack of mechanical ventilation and acetaminophen use were also associated with buprenorphine use. Full agonist opioid use was more frequent on days when buprenorphine was not given (odds ratio [OR], 6.2 [95% CI, 2.3–16.4]; P < .001). Additionally, the average cumulative dose of opioids given on nonbuprenorphine administration days was significantly higher both in the ICU (OR, 1803 [95% CI, 1271–2553] vs OR, 327 [95% CI, 152–708] FEs/day; P < 0.001) and after ICU discharge (OR, 1476 [95% CI, 962–2265] vs OR, 238 [95% CI, 150‐377] FEs/day; P < .001). Given these findings, buprenorphine continuation during critical illness should be considered, as it is associated with significantly decreased full agonist opioid use.

Objective: We aimed to quantify the effect of opioid agonist pharmacotherapy on pain management after cesarean delivery, compared with patients not on these medications. Methods: Patients undergoing cesarean delivery at our institution between January 2016 and December 2018 were stratified by peripartum use of opioid agonist pharmacotherapy versus no agonist therapy. We compared 24-hour postoperative opioid consumption not including buprenorphine and methadone, in milligram morphine equivalents (MME) (primary outcome), highest pain score on a 0 to 10 numerical rating scale in the first 24 postoperative hours, and postoperative length of stay in hours (secondary outcomes) between groups. These outcomes were also compared after covariate adjustment using logistic regression. Results: We identified 123 patients on opioid agonist pharmacotherapyin the form of buprenorphine or methadone and 2856 patients not on these medications. The groups differed in demographic characteristics, including age, smoking, and marital status. Opioid consumption during the first 24 postoperative hours (median [interquartile range]) was 99 [75,120] MME for patients on agonist therapy and 30 [0, 64] MME among parturients not taking these medications (P < 0.001). Highest pain scores during this time were also higher for patients on opioid agonist pharmacotherapy (mean [standard deviation]: 8.2 [1.6] vs 5.5 [2.2], P < 0.001 for the no agonist group). Postoperative length of stay was 73 [68, 77] hours for patients on agonist pharmacotherapy, and 71 [62, 76] hours for parturients taking no agonist (P < 0.001). All differences remained significant after covariate adjustment. Conclusions: Parturients on opioid agonist pharmacotherapy have markedly increased opioid utilization and pain severity after cesarean delivery.