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

Abstract

Opioid use disorder (OUD), a leading cause of morbidity and mortality in the USA, can be effectively treated with buprenorphine. However, the same pharmacologic properties (e.g., high affinity, partial agonism, long half-life) that make it ideal as a treatment for OUD often cause concern among clinicians that buprenorphine will prevent effective management of acute pain with full agonist opioid analgesics. Because of this concern, many patients are asked to stop buprenorphine preoperatively or at the onset of acute pain, placing them at high risk for both relapse and a difficult transition back to buprenorphine after acute pain has resolved. The purpose of this review is to summarize the existing literature for acute pain and perioperative management in patients treated with buprenorphine for OUD and to provide practical management recommendations for generalist practitioners based on evidence and clinical experience. In short, evidence suggests that sufficient analgesia can be achieved with maintenance of buprenorphine and use of both opioid and non-opioid analgesic options for breakthrough pain. We r e c o m m e n d t h a t c l i n i c i a n s ( 1 ) c o n t i n u e buprenorphine in the perioperative or acute pain period for patients with OUD; (2) use a multi-modal analgesic approach; (3) pay attention to care coordination and discharge planning when making an analgesic plan for patients with OUD treated with buprenorphine; and (4) use an individualized approach founded upon shared decision-making. Clinical examples involving mild and severe pain are discussed to highlight important management principles.

Perioperative Pain Management and Opioid Stewardship: A Practical Guide

“…To this effect, a recent clinical practice advisory states, "it is almost always appropriate to continue buprenorphine at the preoperative dose; furthermore, it is rarely appropriate to reduce the buprenorphine dose" [119]. This is supported by current consensus statements and expert reviews [18,[120][121][122][123][124][125][126][127][128]. Rigorous evidence on postoperative pain management in patients on MAT remains urgently needed to quantify these anecdotal benefits and to compare the effects of available perioperative strategies on patient-centered outcomes [115].…”

“…Chronic pain and opioid tolerance are frequently complicated by opioid-induced hyperalgesia, physical dependence, psychological comorbidities, and/or substance use disorders, making postoperative pain more difficult to manage in this population [ 104 , 116 , 117 , 118 ]. These factors contribute to current expert recommendations to continue chronic long-acting opioid agonists throughout the perioperative period, including methadone and buprenorphine [ 18 , 115 , 116 , 119 , 120 , 121 , 122 ]. Methadone and buprenorphine can be prescribed for either chronic pain treatment or as medication-assisted treatment for opioid use disorder (OUD) in the outpatient setting.…”

“…Ceiling effects are observed for respiratory depression and sedation, however, likely conferring a safer risk profile than pure mu-opioid agonists [ 104 , 122 , 129 , 130 , 131 , 132 ]. Buprenorphine has also demonstrated protective effects against opioid-induced hyperalgesia, likely improving postoperative pain responsiveness to therapy [ 121 ]. This notion is supported by retrospective evidence that chronic buprenorphine users exhibit lower postoperative opioid requirements when buprenorphine is given on day of surgery versus when it is not [ 133 ].…”

“…A more nuanced strategy is to temporarily increase and/or divide buprenorphine or methadone dosing starting on the day of surgery to maximize pain control without increasing peak-related adverse effects. This has pharmacologic merit in that the analgesic duration of action for buprenorphine and methadone is far shorter than their active duration for reducing cravings [ 121 , 128 ].…”

“…The patient’s usual total daily dose, or a slightly increased total daily dose, is divided into 2 to 4 doses throughout the day starting on the day of surgery. The patient can then be discharged on their usual preoperative regimen without therapy interruption [ 121 , 125 , 128 ]. Alternatively, some have advocated for a buprenorphine dose reduction in the perioperative period if the patient is on higher chronic doses and/or is experiencing inadequate pain relief despite appropriately dosed as-needed opioids, citing the dose-dependent mu opioid receptor antagonism of buprenorphine [ 119 , 122 , 126 , 132 ].…”