Perioperative opioid requirements of patients receiving sublingual buprenorphine-naloxone: a case series

Abstract

Background Buprenorphine, a partial opioid agonist, displaces full opioid agonists from receptors and may impede surgical pain management. We report the effects of a sublingual formulation of buprenorphine-naloxone, Suboxone ( SL-BUP ), on perioperative pain management. Methods We identified all adult surgical patients from December 31, 2004, to January 1, 2016, who received SL-BUP within 30 days prior to procedures performed with general, regional, or combined general/regional anesthesia. We recorded opioid use during the procedure, in the post-anesthesia care unit (PACU), and during the 24 h following PACU discharge. We also examined opioid use in those who continued SL-BUP until the day of surgery vs those who preoperatively discontinued SL-BUP . Results Thirty-two patients were treated preoperatively with SL-BUP . Three patients had regional anesthesia only, and opioid requirements were case dependent. Requirements were minimal for creation of an arteriovenous fistula and high following knee replacement and cesarean section. Twelve patients received combined general/regional anesthesia, and 17 received general anesthesia only. Intraoperative and PACU opioid use in these 2 groups were not significantly different ( P = .10 and P = .93, respectively). In both groups opioid use increased after discharge from the PACU, and remained comparable between the general and combined general/regional group through the first 24 h after PACU discharge ( P = .78). Although median [interquartile range] 24-h opioid doses were higher among patients who discontinued SL-BUP , the difference was not statistically significant in the general anesthesia–only group ( SL-BUP discontinued, 199 [110–411] mg IV-MEq [intravenous morphine equivalent] vs SL-BUP continued, 106 [58–160] mg IV-MEq; P = .15) or in the combined general/regional group ( SL-BUP discontinued, 140 [100–157] mg IV-MEq vs SL-BUP continued, 100 [73–203] mg IV-MEq; P = .94). Conclusions Regardless of the type of anesthesia used, physicians treating patients with SL-BUP must be prepared to administer large doses of opioids during the early postoperative period. No difference in opioid requirements was noted between patients who perioperatively stopped SL-BUP versus those who continued SL-BUP .

Continuation Versus Discontinuation of Buprenorphine in the Perioperative Setting: A Retrospective Study

“…For patients on buprenorphine therapy in the perioperative period, most commonly, you can divide the treatment plan into three options: continue buprenorphine throughout the perioperative period, discontinue buprenorphine for a period prior to surgery, or increase the buprenorphine dose preoperatively to a maximum dose of 32 mg/day [ 3 , 4 , 9 ]. Unfortunately, the present study does not include any patients whose preoperative buprenorphine dose was changed; thus, our main concern was directly comparing patients who had their buprenorphine continued versus discontinued in the perioperative period.…”

“…Utilizing multimodal analgesia has been repeatedly shown to improve postoperative pain [ 13 ] and is essential for these patients. Regardless, these patients may have high opioid requirements whether they continue or discontinue buprenorphine [ 4 ].…”

“…At sublingual doses of 16 mg, MOR availability is reduced by 79%-95% [ 2 , 8 ]. This displacement can last for several days as buprenorphine has a long and variable half-life, ranging from 16.4 hours to 70 hours [ 3 , 4 ]. Due to its partial agonism, there is an analgesic ceiling effect in which further increases in dosing will not produce any greater analgesic effect [ 4 , 6 ].…”

“…This displacement can last for several days as buprenorphine has a long and variable half-life, ranging from 16.4 hours to 70 hours [ 3 , 4 ]. Due to its partial agonism, there is an analgesic ceiling effect in which further increases in dosing will not produce any greater analgesic effect [ 4 , 6 ]. Finally, when buprenorphine is combined with naloxone, there is a decreased risk for abuse.…”

Perioperative Management of Patients on Buprenorphine and Methadone: A Narrative Review

“…A multimodal pain management approach with the use of dexmedetomidine, remifentanil, and ketamine perioperatively has shown success in providing adequate pain control among patients taking buprenorphine for OUD ( 25 , 26 ). The use of regional anesthesia, though reasonable, was inconsistent in terms of decreasing the amount of opioid used in the perioperative period in one case series ( 25 ). In patients who are on a low dose of buprenorphine, that is 2-8 mg per day, buprenorphine can be continued as an analgesic by increasing the frequency of the dose in every 6-8 hours ( 21 ).…”