Effect of Buprenorphine on Total Intravenous Anesthetic Requirements During Spine Surgery

Abstract

Buprenorphine is a partial mu receptor agonist and kappa/delta antagonist commonly used for the treatment of opioid dependence or as an analgesic. It has a long plasma halflife and a high binding affinity for opioid receptors. This affinity is so high, that the effects are not easily antagonized by competitive antagonists, such as naloxone. The high affinity also prevents binding of other opioids, at commonly used clinical doses, to receptor sites – preventing their analgesic and likely minimum alveolar concentration (MAC) reducing benefits. This case report contrasts the anesthetic requirements of a patient undergoing emergency cervical spine surgery while taking buprenorphine with anesthetic requirements of the same patient undergoing a similar procedure after weaning of buprenorphine. Use of intraoperative neurophysiological monitoring prevented use of paralytics and inhalational anesthetics during both cases, therefore total intravenous anesthesia (TIVA) was maintained with propofol and remifentanil infusions. During the initial surgery, intraoperative patient movement could not be controlled with very high doses of propofol and remifentanil. The patient stopped moving in response to surgical stimulation only after the addition of a ketamine. Buprenorphine-naloxone was discontinued postoperatively. Five days later the patient underwent a similar cervical spine surgery. She had drastically reduced anesthetic requirements during this case, suggesting buprenorphine’s profound effect on anesthetic dosing. This case report elegantly illustrates that discontinuation of buprenorphine is likely warranted for patients who present for major spine surgery, which necessitates the avoidance of volatile anesthetic and paralytic agents. The addition of ketamine may be necessary in patients maintained on buprenorphine in order to ensure a motionless surgical field. Key words: Buprenorphine, anesthesiology, intraoperative, total intravenous anesthesia, pharmacology

Treating Perioperative and Acute Pain in Patients on Buprenorphine: Narrative Literature Review and Practice Recommendations

“…Tables 1 and 2 summarize the existing literature on perioperative pain management of patients on buprenorphine. Nine case reports [33][34][35][36][37][38][39][40][41] and two case series, 42,43 comprising a total of 17 cases, were identified that described perioperative course or pain management after traumatic injury among patients treated with buprenorphine for chronic pain or OUD (Table 2). In 12 of the 15 cases where buprenorphine was continued (5 case reports, plus 8 cases from the 2 case series), adequate pain control was achieved.…”

“…33,38,[41][42][43] Discontinuing buprenorphine was only required in three of the cases. 36,39,40 Of note, pain control in these patients required multi-modal management and titration of medication, including regional pain blocks 35 and adjustment of buprenorphine dose. 38 In the two cases where buprenorphine was discontinued 3-5 days preoperatively, it was difficult to achieve adequate pain control in the perioperative period.…”

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

“…Managed on oral hydromorphone at time of discharge. Recommendation: discontinue buprenorphine.Khelemsky Y et al153 Case report A woman aged 44 years with cervical spine surgeries 5 days apart. Patient had reduced total intravenous anesthesia requirements for the latter surgery when Suboxone (8/2 mg, three times a day) was stopped after first surgery.Weaning of Suboxone preoperatively is suggested.Silva MJ et al77 Case report A man aged 53 years had one total knee arthroplasty on each knee approximately 2 years apart.…”

Comparison Between Preoperative Methadone and Buprenorphine Use on Postoperative Opioid Requirement

“…15 Several reports have described postoperative pain despite high doses of opioid analgesics in patients on buprenorphine preoperatively. [16][17][18] However, available studies suffer from small sample sizes and lack power to detect clinically meaningful differences in pain intensity or opioid dose requirements between patients on buprenorphine and those in comparison groups.…”

“…In contrast, buprenorphine dose dependently decreases mu-receptor availability for other full agonists at its therapeutic dose range (buprenorphine at a dose of 16 mg occupies >80% of available mu-opioid receptors), which potentially makes postoperative pain management difficult, requiring high doses of opioids 15. Several reports have described postoperative pain despite high doses of opioid analgesics in patients on buprenorphine preoperatively 16–18. However, available studies suffer from small sample sizes and lack power to detect clinically meaningful differences in pain intensity or opioid dose requirements between patients on buprenorphine and those in comparison groups.…”