Effectiveness of Transdermal Buprenorphine for Pain Control in the ICU After Major Surgical Procedures

Abstract

OBJECTIVES: Transdermal buprenorphine (TBUP) may be useful for postoperative pain after major surgery, when pain is expected to be severe and sustained. The objective of this study was to compare pain control and opioid consumption in critically ill postoperative patients who were treated with TBUP or not during ICU admission. DESIGN: This was a retrospective, parallel, cohort study. SETTING: ICU of a quaternary, urban hospital in Sydney, Australia. PATIENTS: Data were obtained for all patients admitted to the ICU from January 2019 to July 2021 after major gastrointestinal (GI) or genitourinary (GU) surgery. INTERVENTIONS: TBUP or non-TBUP. MEASUREMENTS AND MAIN RESULTS: Pain control was compared between patients who received TBUP and those who did not receive TBUP. The primary outcome was the probability of significant pain. A significant pain score was defined as greater than or equal to 4 on the 0–10 numeric rating scale or greater than or equal to 6 on the behavioral pain scale. Inverse probability of treatment weighting was used to adjust for baseline differences. The cohort included 376 patients, with 224 (60%) in the control group and 152 (40%) in the TBUP group. The mean age was 60 ± 14 years, 202 (54%) were male, mean Acute Physiology and Chronic Health Evaluation III score was 44 ± 13, and 147 (39%) received mechanical ventilation. After adjustment, the median probability of significant pain was 0.25 with control and 0.30 with TBUP (median difference, 0.02; 95% CI, 0.04–0.11; p = 0.44). The median opioid consumption (oral morphine milligram equivalents) per day was 5.7 mg with control and 10.1 mg with TBUP (median difference, 0.4 mg; 95% CI, –0.4 to 3.7 mg; p = 0.31). CONCLUSIONS: In patients who are admitted to the ICU after major GI or GU procedures, the use of TBUP in the ICU was not associated with improved pain control or opioid consumption compared with those who did not receive TBUP.

Acute Pain Management for Patients Maintained on Sublingual Buprenorphine as Medication for Opioid Use Disorder

“…Daily average MME requirements were considerably lower than 1 would expect to adequately manage acute pain, which may have been impacted by baseline characteristics or inclusion and exclusion criteria. The MME requirements from full opioid agonists of patients continued on buprenorphine has not been well studied; however, a retrospective cohort 13 reported mean daily MME use in ICU patients newly initiated on transdermal buprenorphine after major gastrointestinal or genitourinary surgery to be 10.1 MME, which does align with our findings.…”

“…1,4,5 Therefore, full mu-opioid agonists can continue to be used for additional analgesia in conjunction with buprenorphine. [3][4][5][6][7][8][9]11,12 Despite more recent guidance to continue buprenorphine throughout hospitalization, 7,9,13 questions still remain regarding the optimal buprenorphine dose required to optimize the efficacy of additional analgesics required for acute pain management. Because of a paucity of evidence comparing variable buprenorphine doses and patient outcomes, existing institutional pathways for acute pain management in OUD patients are largely based on pharmacokinetic mu-receptor availability data and differ in recommended dose to be continued.…”

Effectiveness of Sublingual Buprenorphine for Pain Control in the ICU*

“…Thus, there was no basis to juxtapose these findings to previous investigations. There was a previous observational study ( n = 375) evaluating the use of transdermal buprenorphine in ICU patients who had undergone major gastrointestinal and genitourinary surgeries, which did not show a benefit compared with not using transdermal buprenorphine (15). In the aforementioned study, oxycodone use was possible in both groups and was not a comparison of buprenorphine versus oxycodone.…”

“…Data were also obtained from the ANZICS APD at the institution. The following definitions were used similar to a previous investigation (15): 1) probability of significant pain: number of pain scores with significant pain divided by the total number of pain scores. A significant pain score is defined as greater than or equal to 4 on the 0–10 NRS or greater than or equal to 6 on the BPS (16).…”

“…Based on a prior study using the transdermal formulation of buprenorphine and the same outcome measure (15), we estimated that the probability of significant pain to be 0.25 (i.e., number of significant pain scores divided by the total number of pain scores). Assuming a difference in probability of 0.10 with buprenorphine sublingual and using a common sd of 0.3, two-sided alpha of 0.05, and power of 80%, we estimated that 143 patients would be required in each group (286 total).…”