Buprenorphine management in the perioperative period: educational review and recommendations from a multisociety expert panel

Abstract

BackgroundThe past two decades have witnessed an epidemic of opioid use disorder (OUD) in the USA, resulting in catastrophic loss of life secondary to opioid overdoses. Medication treatment of opioid use disorder (MOUD) is effective, yet barriers to care continue to result in a large proportion of untreated individuals. Optimal analgesia can be obtained in patients with MOUD within the perioperative period. Anesthesiologists and pain physicians can recommend and consider initiating MOUD in patients with suspected OUD at the point of care; this can serve as a bridge to comprehensive treatment and ultimately save lives.MethodsThe Board of Directors of the American Society of Regional Anesthesia and Pain Medicine, American Society of Anesthesiologists, American Academy of Pain Medicine, American Society of Addiction Medicine and American Society of Health System Pharmacists approved the creation of a Multisociety Working Group on Opioid Use Disorder, representing the fields of pain medicine, addiction, and pharmacy health sciences. An extensive literature search was performed by members of the working group. Multiple study types were included and reviewed for quality. A modified Delphi process was used to assess the literature and expert opinion for each topic, with 100% consensus being achieved on the statements and each recommendation. The consensus statements were then graded by the committee members using the United States Preventive Services Task Force grading of evidence guidelines. In addition to the consensus recommendations, a narrative overview of buprenorphine, including pharmacology and legal statutes, was performed.ResultsTwo core topics were identified for the development of recommendations with >75% consensus as the goal for consensus; however, the working group achieved 100% consensus on both topics. Specific topics included (1) providing recommendations to aid physicians in the management of patients receiving buprenorphine for MOUD in the perioperative setting and (2) providing recommendations to aid physicians in the initiation of buprenorphine in patients with suspected OUD in the perioperative setting.ConclusionsTo decrease the risk of OUD recurrence, buprenorphine should not be routinely discontinued in the perioperative setting. Buprenorphine can be initiated in untreated patients with OUD and acute pain in the perioperative setting to decrease the risk of opioid recurrence and death from overdose.

Opioid abuse and perioperative care: a new medical disease

“…At discharge, it is important to coordinate with the patient's OUD treatment prescriber to ensure that a follow-up plan is in place so that the patient can be weaned back to their baseline OUD regimen when appropriate [14 ▪▪ ]. Importantly, this institution is also amongst a few in the country that has used continuous, portable vital sign monitoring for postoperative patients for the last 5 years, thereby reducing patient safety events secondary to opioids [31,32].…”

Perioperative and Periprocedural anesthetic management of opioid tolerant patients and patients with active and medically treated opioid use disorder

“…Lastly, the decision to discharge a patient with opioids, while typically at the surgeon/proceduralist's discretion, should involve a multidisciplinary team discussion, including both the patient and the patient's primary prescriber. Close follow-up care is essential; careful discharge instructions should be provided regarding medications and tapering plans, and postoperative appointments should be scheduled with the surgical team, the patient's primary prescriber, and any other clinically appropriate teams [1 ▪▪ ]. As recovery goes on, a return to baseline functionality is the goal for these patients.…”

“…Patients presenting for surgery may exhibit opioid tolerance secondary to chronic opioid therapy for chronic pain, active OUD, or a history of OUD treated with medication. In response to the opioid epidemic, an increasing number of patients with OUD are being transitioned to medications for the treatment of opioid use disorder (MOUD), formerly known as medication-assisted treatment [1 ▪▪ ]. Medications approved for the treatment of OUD include buprenorphine (with or without naloxone), methadone, and naltrexone, all of which have unique implications and management strategies in the perioperative period.…”

Response to incorrect application of DSM-5 criteria

“…We sincerely appreciate Dr Balasanova’s letter1 and close reading of our paper2 and recognize that we erred in noting that a pharmacologic criterion must be met to establish the diagnosis of opioid use disorder per DSM-5; this is not the case. Additionally, we are aware that the four explanatory categories that are used to educate regarding the substance use disorder (SUD) diagnosis are not in the DSM-5; however, as this paper was directed primarily at non-addiction healthcare practitioners, we opted to use them in order to provide a helpful framework for understanding the SUD condition as a whole.…”