Dexmedetomidine as a novel therapeutic for postoperative pain in a patient treated with buprenorphine

Abstract

Buprenorphine is a partial agonist/antagonist used for the outpatient management of pain and addiction. It avidly binds to the opioid receptors and has a long and varied half-life. Its effects can impair the efficacy of opioids used for postoperative pain. The authors present a case of a patient managed with buprenorphine as an outpatient who presented for revision spine surgery and had significant postoperative pain that was successfully treated with hydromorphone and dexmedetomidine. This is the first reported use of dexmedetomidine for postoperative pain in a patient treated with buprenorphine.

The perioperative patient on buprenorphine: a systematic review of perioperative management strategies and patient outcomes

“…A majority, 72% (13/18), were CRs or case series ( Table 2). [13][14][15][16][17][18][19][20][21][22][23][24][25] Only one true case series was identified, with five of the CRs including single patients who underwent two surgeries at different time points. A total of 17 patients were included in the CRs and case series, five of whom underwent two procedures at different time points.…”

“…Interestingly, in CRs with complete reporting (eight articles, 16 cases in total), every patient whose buprenorphine was discontinued and experienced poorly controlled pain was taking 16 mg SL daily or greater preoperatively. 16,22,25 In fact, pain was successfully controlled in all but one of the patients taking 16 mg buprenorphine SL daily or greater who continued buprenorphine. [13][14][15][16]18,23 Clinically correlated pharmacokinetic studies are required to confirm this cutoff, especially in the context of high inter-patient variability.…”

Case Series of Successful Postoperative Pain Management in Buprenorphine Maintenance Therapy Patients

“…Some authors report poor pain control until discontinuation of the buprenorphine. 17 , 18 Factors other than opioid-binding properties, such as the preoperative buprenorphine dose, the nature of the surgery, and the use of regional anesthesia and nonopioid pain control adjuvants, are also important to consider during postoperative pain management.…”

“…Ketamine and dexmedetomidine have been successfully added to multimodal analgesia in BMT patients. 18 , 19 We did not use either drug but encourage other clinicians to consider doing so.…”

Perioperative management in children with chronic pain

“…Benzodiazepines administered with buprenorphine have been shown to exert a synergistic effect in the central nervous system causing sedation and respiratory depression that has been linked to fatalities . Perioperatively, buprenorphine may be continued and dose adjusted appropriately or be discontinued preoperatively and a mu opioid may be substituted . Either of these options may be combined with multiple nonopioid analgesics and regional anesthesia where possible .…”