Guidelines on the Perioperative Pain Management of Patients on Buprenorphine Therapy

Clinical best practice recommendations for the use of buprenorphine in the perioperative management of patients undergoing interventional pain procedures and other surgeries were recently published in Pain Physician.¹

Buprenorphine can prevent the binding of additional opioid medications to opioid receptors during surgery and was found to have a ceiling effect for analgesia.² The goal of this literature review was to provide recommendations for the perioperative and postoperative management of patients on buprenorphine therapy.

The investigators based these guidelines on 1 randomized clinical trial, 1 prospective case-matched cohort, 1 retrospective cohort study, 4 case reports, and 6 review articles found on PubMed and focused on perioperative buprenorphine management.

These studies indicate that patients with a history of opioid abuse or dependence are at a high risk for relapse after surgery if severe postoperative pain is managed with buprenorphine alone.

Here are the recommendations they formulated:

• Buprenorphine and naloxone therapy should be halted and a high-dose of pure opioid agonist should be initiated while increasing the use of adjuvant non-opioid medications.
• Buprenorphine therapy should be held during the perioperative period to support adequate analgesia during surgery to lower the risk for subsequent opioid abuse relapse.
• Patients who use buprenorphine for chronic pain vs relapse prevention are considered at lower risk for relapse and abuse of pure opioid agonists. Therefore, medication for patients with chronic pain should be transitioned to pure opioid agonists 1 to 2 days before an operation.
• Adjuvant non-opioid therapies, such as epidural catheters and peripheral nerve block catheters, are options that should be considered whenever appropriate.
• Buprenorphine therapy should be discontinued 3 to 5 days before a scheduled surgery if the surgery is likely to result in a high opioid requirement.

For patients who are considered at high risk for relapse into opioid abuse, the investigators conclude: “The decision to resume buprenorphine preparations should be made by collaborative efforts between the primary prescriber, surgeon, and anesthesiologist, ideally when the patient’s postoperative pain requirements have subsided.”

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References

1. Urman RD, Jonan AB, Kaye AD. Buprenorphine formulations: clinical best practice strategies recommendations for perioperative management of patients undergoing surgical or interventional pain procedures. Pain Physician. 2018;21(1):E1-E12.
2. Johnson RE, Fudala PJ, Payne R. Buprenorphine: considerations for pain management. J Pain Symptom Manage. 2005;29(3):297-326.