To Stop or Not, That Is the Question

Abstract

Perioperative pain management suggestions for patients taking buprenorphine and presenting for elective and urgent/emergent surgery have been developed and are described here.

<p>Perioperative Pain Management for Median Sternotomy in a Patient on Chronic Buprenorphine/Naloxone Maintenance Therapy: Avoiding Opioids in Patients at Risk for Relapse</p>

“…The clinical evidence for managing surgical patients on therapeutic buprenorphine-naloxone regimen is based on anecdotal experience from case reports/series and institutional experience with no randomized studies and no long-term outcome results. 2,6 Despite the limited evidence, protocols for the management of these patients have recently been published. 2,6,7 Consensus in the management of patients in advance of procedures with expected moderate to severe postoperative pain is to hold buprenorphine-naloxone 72 hrs prior to surgery.…”

“…2,6 Despite the limited evidence, protocols for the management of these patients have recently been published. 2,6,7 Consensus in the management of patients in advance of procedures with expected moderate to severe postoperative pain is to hold buprenorphine-naloxone 72 hrs prior to surgery. 8,9 However, this option was not optimal in our patient.…”

“…Buprenorphine maintenance therapy patients frequently have severe postoperative pain due to buprenorphine induced hyperalgesia and limited efficacy of intraoperative opioids in the presence of buprenorphine. 2,3 We present a 26-year-old man with a history of opioid abuse on maintenance therapy with buprenorphine-naloxone who presented for median sternotomy, cardiopulmonary bypass, and pulmonary valve replacement. The patient requested continuation of buprenorphine-naloxone during the perioperative period and avoidance of additional perioperative opioids in order to decrease the risk of relapse of his opioid addiction.…”

Perioperative Management of a Patient Taking Suboxone® at the Time of Ambulatory Surgery

“…However, due to its unique pharmacodynamics properties, it presents a unique challenge to anesthesiologists trying to treat acute pain in the perioperative setting [4,5]. Although there is no consensus regarding optimal perioperative management of patients taking these medications, most strategies include a multimodal pain control approach with recommendations ranging from continuing buprenorphine and supplementing with full opioid agonists as necessary, to discontinuing buprenorphine preoperatively in exchange for full opioid agonists [6,7]. Utilizing a multimodal approach to pain control allows for blockade of pain transmission at multiple sites along the nervous system as well as blockade of a variety of pain receptors with less dangerous side effects (Figure 1 and 2).…”

Case Series of Successful Postoperative Pain Management in Buprenorphine Maintenance Therapy Patients

“…Third, many obstetricians refuse to ask their pregnant patients to abstain from buprenorphine because they fear unmonitored and untreatable fetal withdrawal symptoms. A multimodal approach to BMT patients was recently described by Anderson et al 14 We utilized a similar multimodal approach in the 4 obstetric cases described.…”