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

Abstract

Buprenorphine maintenance therapy patients frequently have severe postoperative pain due to buprenorphine-induced hyperalgesia and provider use of opioids with limited efficacy in the presence of buprenorphine. The authors report good-to-excellent pain management in 4 obstetric patients using nonopioid analgesics, regional anesthesia, continuation of buprenorphine, and use of opioids with high μ receptor affinity.

Managing Opioid Withdrawal in the Emergency Department With Buprenorphine

“…[25][26][27] For example, the relative antagonism after administration of a large dose of buprenorphine (partial agonist/high binding affinity) to a patient receiving methadone (full agonist/low binding affinity) will likely result in precipitated opioid withdrawal, whereas patients receiving buprenorphine can receive full-agonist opioids for analgesia without concern for precipitated opioid withdrawal. [28][29][30] The relief provided by buprenorphine increases with worsening opioid withdrawal severity and increased dose of buprenorphine. Although a Clinical Opiate Withdrawal Scale score of 8 is a suggested minimum for initiation by some guidelines, at least one objective sign of opioid withdrawal indicates readiness to initiate buprenorphine.…”

<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>

“…10 There are four practical options for perioperative buprenorphine management: 3 (1) continue buprenorphine and use traditional opioids with high μ affinity (hydromorphone or sufentanil) 11 (2) reduce buprenorphine preoperatively to increase availability of μ opioid receptors. 3,12 (3) continue buprenorphine with supplemental postoperative buprenorphine 13 or (4) discontinue buprenorphine preoperatively and start traditional opioid prior to the surgery. 9 With the first and second approach of continuing buprenorphine, there is concern that traditional opioids will not be as effective and pain will be difficult to control.…”

“…When opioid analgesia is needed, sufentanil and hydromorphone have a similar or higher affinity for the µ receptor and can be used to displace buprenorphine if opioids are needed. 3 With the third approach of continuing buprenorphine, there is some evidence that perioperative buprenorphine may provide some postoperative analgesia and would support this approach. 13 With the last approach of discontinuing buprenorphine and starting a traditional opioid, there is concern of relapse in the patient with opioid abuse history.…”

“…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

“…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). Multiple case reports illustrate the unpredictability of pain control in these patients despite utilizing these strategies [8][9][10].…”