New Pain Management Options for the Surgical Patient on Methadone and Buprenorphine

Abstract

Perioperative management of patients receiving opioid addiction therapy presents a unique challenge for the anesthesiologist. The goal of pain management in this patient population is to effectively manage postoperative pain, to improve patient satisfaction and outcomes, and to reduce the cost of health care. Multimodal analgesics, including nonsteroid anti-inflammatory drugs, intravenous acetaminophen, gabapentanoid agents, and low-dose ketamine infusions, have been used to improve postoperative pain and to reduce postoperative opioid use. Patients on long-term opioid management therapy with methadone and buprenorphine require special considerations. Recommendations and options for treating postoperative pain in patients on methadone and buprenorphine are outlined below. Other postoperative pain management options include patient-controlled analgesia, intravenous, and transdermal, in addition to neuraxial and regional anesthesia techniques. Special patient populations include the parturient on long-term opioid therapy. Recommendations for use of opioids in these patients during labor and delivery and in the postpartum period are discussed.

Acute Pain Management in Hospitalized Adult Patients with Opioid Dependence: A Narrative Review and Guide for Clinicians

“…Recommendations regarding acute pain management in patients being treated with buprenorphine are largely based on expert opinion. Treatment options include [32][33][34] :…”

Buprenorphine with, or without, Naloxone for Pregnant Women?–Review of Current Evidence and Practice in Massachusetts

“…Buprenorphine's high affinity for opioid receptors can present a challenge in certain unique circumstances demanding urgent or emergent analgesia and anaesthesia [9,10,12]. a property which methadone, with its weaker receptor binding, does not share.…”

“…Paradoxically, Massachusetts currently provides unrestricted access only to the buprenorphine/naloxone co-formulated films for Mass Health beneficiaries [42]. Available reviews show the challenges the anaesthesiologists face to achieve appropriate anaesthesia/analgesia in buprenorphine treated individuals [9,10]. Naloxone, with its shorthalf-life, however, plays no role in this aspect.…”

“…The partial agonist activity creates a "ceiling effect", where administration of more buprenorphine, past a certain dose, does not produce more effect, which limits its acute toxicity and overdose potential [8]. In addition to having a ceiling on its own effects, buprenorphine also has a relatively high affinity for the μ-opioid receptor compared to most opioids, making it capable of blocking the euphoric and potential overdosing effects of other opioids if coadministered [9,10]. Buprenorphine has an exceptionally long half-life (estimates range from 3-44 h for buprenorphine and up to 176 h for nor-buprenorphine, its main active metabolite), and clinical case reports describing difficulty overcoming buprenorphine's effects to achieve adequate analgesia confirm that the effect of buprenorphine and its metabolites can remain clinically significant for up to 72 h [9].…”

“…In addition to having a ceiling on its own effects, buprenorphine also has a relatively high affinity for the μ-opioid receptor compared to most opioids, making it capable of blocking the euphoric and potential overdosing effects of other opioids if coadministered [9,10]. Buprenorphine has an exceptionally long half-life (estimates range from 3-44 h for buprenorphine and up to 176 h for nor-buprenorphine, its main active metabolite), and clinical case reports describing difficulty overcoming buprenorphine's effects to achieve adequate analgesia confirm that the effect of buprenorphine and its metabolites can remain clinically significant for up to 72 h [9]. Other unique properties of buprenorphine include that it may produce milder withdrawal symptoms than full agonists if abruptly discontinued [11].…”