Perioperative Continuation of Buprenorphine at Low–Moderate Doses Was Associated with Lower Postoperative Pain Scores and Decreased Outpatient Opioid Dispensing Compared with Buprenorphine Discontinuation

Abstract

Objective An increasing number of individuals are prescribed buprenorphine as medication-assisted treatment for opioid use disorder. Our institution developed guidelines for perioperative buprenorphine continuation with an algorithm for dose reduction based upon the surgical procedure and patient's maintenance dose. The objective of this study was to compare the effects of buprenorphine continuation with those of discontinuation on postoperative pain scores and outpatient opioid dispensing. Design Retrospective observational study. Subjects Surgical patients on buprenorphine from March 2018 to October 2018. Patients on buprenorphine for chronic pain and those with minor procedures were excluded from analysis. Methods We compared postoperative outpatient opioid dispensing and postanesthesia care unit (PACU) pain scores in patients where buprenorphine was continued compared with held perioperatively, collecting single surgical subspecialty prescriber data on outpatient full mu-opioid agonist prescriptions dispensed, converted into mean morphine equivalents. Buprenorphine formulations were not included in our morphine milligram equivalents (MME) total. Results There were 55 patients total (38 cont. vs 17 held). There was no difference in postoperative buprenorphine treatment adherence (91% cont. vs 88% held, P = 0.324). The number of opioid prescriptions dispensed was significantly higher with buprenorphine discontinuation (53% cont. vs 82% held, P = 0.011), as was MME dispensed (mean of 229 cont. vs mean of 521 held, P = 0.033). PACU pain scores were higher with buprenorphine discontinuation (mean 2.9 cont. vs mean 7.6 held, P < 0.001). Conclusions There was a significant reduction in opioid prescriptions filled, MME dispensed, and PACU pain scores in patients where buprenorphine was continued vs held perioperatively. We provide evidence to support that buprenorphine can be continued perioperatively and that continuation is associated with decreased postoperative pain and decreased outpatient opioid dispensing. These results contribute to the existing literature supporting the perioperative continuation of buprenorphine.

Peripartum and Postpartum Analgesia and Pain in Women Prescribed Buprenorphine for Opioid Use Disorder Who Deliver by Cesarean Section

“…Buprenorphine was not included in daily MME total. 6 , 10 Maternal daily dose of buprenorphine was categorized as low (⩽10 mg), medium (11–15 mg) or high (⩾ 16 mg).…”

“…More recent evidence suggests that full agonist opioids can be used to treat postsurgical pain in patients maintained on buprenorphine throughout hospitalization. However, some specialists have suggested reducing the daily dose of buprenorphine prior to surgery 6 whereas 2 systematic reviews suggested that buprenorphine could be continued perioperatively at doses ⩽16 mg daily. 7 , 8 A recent multidisciplinary workgroup suggested that there was a moderate level of evidence that patients on buprenorphine should be continued at their home dose during the preoperative period and that multimodal analgesia including short-acting full agonist opioids could be used during the postoperative phase.…”

Experiences with an Addiction Consultation Service on Care Provided to Hospitalized Patients with Opioid use Disorder: A Qualitative Study of Hospitalists, Nurses, Pharmacists, and Social Workers

“…55,56 Increasingly, experts recommend continuing buprenorphine in the perioperative period to avoid the risk of relapse to illicit opioid use. [57][58][59][60][61][62] Integrating evidenced-based recommendations for pain management among people with OUD in the form of easily accessible electronic protocols, as suggested by the pharmacists included in our study, could reduce difficulties related to pain management in patients with OUD. Nurses and hospitalists described challenges in communication as a factor contributing to difficult pain management in patients with OUD.…”

Postoperative respiratory depression in patients on sublingual buprenorphine: a retrospective cohort study for comparison between postoperative continuation and discontinuation of buprenorphine

“…However, several recent studies reported higher pain scores [ 8 ] and a trend towards larger opioid dose requirements in the immediate postoperative period in patients who discontinued, versus continued, buprenorphine perioperatively [ 9 ]. Therefore, it is possible that patients who continue to receive buprenorphine postoperatively may experience less pain and require smaller dose of opioids, which results in less respiratory depression.…”