The perioperative management of patients maintained on medications used to manage opioid addiction

Abstract

When possible, patients maintained on buprenorphine should be evaluated preoperatively to assess the feasibility of discontinuing the buprenorphine 72 h before surgery. If buprenorphine is continued during the perioperative period, patients may require significantly increased doses of standard opioids for analgesia. Patients maintained on methadone are at increased risk for respiratory-related complications and should receive a higher level of monitoring during the perioperative period. Patients who are on chronic methadone should continue their maintenance dose during the perioperative period. Where possible, nonopioid medications and regional anesthetic blockade are effective alternatives for analgesia in this population.

Managing Opioid-Tolerant Patients in the Perioperative Surgical Home

“…For patients who continue taking buprenorphine-naloxone through the perioperative period, buprenorphine can provide sufficient and potent opioid analgesia as a partial mu-opioid agonist, and for minor procedures may be adequate without much supplementation (13). For major surgery, however, additional analgesics will likely be needed.…”

“…These patients have tolerance to opioids, but may also have increased pain sensitivity (13). Patients on methadone for both chronic pain or methadone maintenance therapy (MMT) should continue their scheduled regimen perioperatively to avoid fluctuations in methadone levels given its long half-life (13,14).…”

Caring for patients with opioid use disorder in the hospital

“…Given its high affinity for the opioid μ receptor, buprenorphine effectively blocks the actions of most other opioids, thereby complicating acute pain management. 41 Several strategies have been described to overcome this problem, predominantly based in expert opinion. The first is to continue daily buprenorphine and add short-acting opioids titrated to pain control.…”

“…26,42 Doses of 4-8 mg every six to eight hours have been used to treat moderate to severe pain. 41,43 A third strategy is to discontinue buprenorphine and use short-acting opioids to treat the acute pain. The blocking effects of buprenorphine wear off over 24-72 hours, so the patient must be carefully monitored for signs of overdose, given that the initial opioid dose will be much higher than ultimately needed.…”

“…High-dose opioids, and possibly patient-controlled analgesia, will likely be needed. 26,39,[41][42][43] A second strategy uses the inherent analgesic properties of buprenorphine by giving the total daily dose divided three or four times daily. 26,42 Doses of 4-8 mg every six to eight hours have been used to treat moderate to severe pain.…”