Perioperative Pain and Addiction Interdisciplinary Network (PAIN) clinical practice advisory for perioperative management of buprenorphine: results of a modified Delphi process

Abstract

Until recently, the belief that adequate pain management was not achievable while patients remained on buprenorphine was the impetus for the perioperative discontinuation of buprenorphine. We aimed to use an expert consensus Delphibased survey technique to 1) specify the need for perioperative guidelines in this context and 2) offer a set of recommendations for the perioperative management of these patients. The major recommendation of this practice advisory is to continue buprenorphine therapy in the perioperative period. It is rarely appropriate to reduce the buprenorphine dose irrespective of indication or formulation. If analgesia is inadequate after optimisation of adjunct analgesic therapies, we recommend initiating a full mu agonist while continuing buprenorphine at some dose. The panel believes that before operation, physicians must distinguish between buprenorphine use for chronic pain (weaning/conversion from longterm high-dose opioids) and opioid use disorder (OUD) as the primary indication for buprenorphine therapy. Patients should ideally be discharged on buprenorphine, although not necessarily at their preoperative dose. Depending on analgesic requirements, they may be discharged on a full mu agonist. Overall, long-term buprenorphine treatment retention and harm reduction must be considered during the perioperative period when OUD is a primary diagnosis. The authors recognise that inter-patient variability will require some individualisation of clinical practice advisories. Clinical practice advisories are largely based on lower classes of evidence (level 4, level 5). Further research is required in order to implement meaningful changes in practitioner behaviour for this patient group.

Perioperative Pain Management and Opioid Stewardship: A Practical Guide

“…Chronic pain and opioid tolerance are frequently complicated by opioid-induced hyperalgesia, physical dependence, psychological comorbidities, and/or substance use disorders, making postoperative pain more difficult to manage in this population [ 104 , 116 , 117 , 118 ]. These factors contribute to current expert recommendations to continue chronic long-acting opioid agonists throughout the perioperative period, including methadone and buprenorphine [ 18 , 115 , 116 , 119 , 120 , 121 , 122 ]. Methadone and buprenorphine can be prescribed for either chronic pain treatment or as medication-assisted treatment for opioid use disorder (OUD) in the outpatient setting.…”

“…Preoperative discontinuation of buprenorphine is no longer recommended [ 18 , 119 , 120 , 122 , 126 , 132 ]. Complete buprenorphine cessation can lead to opioid withdrawal syndrome if sufficient alternative opioid agonists are not administered, and standard perioperative protocols may not be adequate for this purpose.…”

“…This is especially problematic in a population that may be experiencing opioid-induced hyperalgesia, uncontrolled pain, unmet psychosocial needs, continuity of care gaps, and access to non-prescribed opioids in the postoperative period. While clinical data is limited, expert opinion cites this dynamic as a key driver of postoperative opioid misuse and opioid use disorder development or relapse [ 74 , 119 , 120 , 122 , 123 , 126 ].…”

Perioperative Pain and Addiction Interdisciplinary Network (PAIN): consensus recommendations for perioperative management of cannabis and cannabinoid-based medicine users by a modified Delphi process

“…This guidance is the result of reviewing available medical literature 2 and of the consensus of a panel of international experts obtained using a modified Delphi technique. The modified Delphi technique used was based on the RAND/UCLA Appropriateness Method developed by the RAND Corporation, and also on the modified Delphi method used by Goel and colleagues 5 and Fitch and colleagues 6 to create consensus guidelines for the perioperative management of buprenorphine.…”

Progress in pain medicine: where are we now?

“…20,21 Using a Delphi approach, clinical recommendations have been developed, with key recommendations to continue buprenorphine throughout the perioperative period, with careful consideration of discharge planning. 22 The importance of continued review and assessment of all patients on strong opioids after surgery may be one way to reduce longer-term problems. 16 There has been a considerable amount of research on the progression of acute to chronic pain after surgery, with much greater understanding of this problem since it was first systematically studied several decades ago.…”