From the Guidelines
For patients on Suboxone (buprenorphine) undergoing non-emergent surgery, the recommended protocol is to continue the medication throughout the perioperative period rather than discontinuing it. This approach is supported by the most recent and highest quality study, which suggests that continuing buprenorphine therapy in the perioperative period is the best practice 1. The Perioperative Pain and Addiction Interdisciplinary Network clinical practice advisory recommends that buprenorphine therapy be continued in the perioperative period and that it is rarely appropriate to reduce the dose, irrespective of the indication or formulation 1.
Key Considerations
- Patients should take their usual Suboxone dose on the day of surgery.
- For postoperative pain management, higher doses of full opioid agonists should be used to overcome buprenorphine's high receptor affinity, with careful monitoring for respiratory depression.
- Short-acting opioids like fentanyl, hydromorphone, or oxycodone are preferred, typically at doses 1.5-2 times higher than standard.
- Regional anesthesia and non-opioid analgesics (acetaminophen, NSAIDs, gabapentinoids, ketamine) should be maximized when appropriate.
- The older practice of discontinuing Suboxone 48-72 hours before surgery is no longer recommended as it risks withdrawal, loss of opioid tolerance, and potential relapse.
Emergent Surgery
In cases of emergent surgery where weaning is not possible, the patient's usual Suboxone dose should still be continued, and postoperative pain management should be tailored to the individual's needs, using higher doses of full opioid agonists as necessary, while carefully monitoring for respiratory depression 1.
Multidisciplinary Approach
Close coordination between the surgeon, anesthesiologist, pain specialist, and addiction medicine provider is essential for optimal outcomes. This team-based approach ensures that the patient's opioid use disorder treatment is maintained while also providing adequate pain control during the perioperative period.
From the FDA Drug Label
DOSAGE AND ADMINISTRATION • Buprenorphine hydrochloride should be prescribed only by healthcare professionals who are knowledgeable about the use of opioids and how to mitigate the associated risks.
In high-risk patients (e.g., elderly, debilitated, presence of respiratory disease, etc.) and/or in patients where other CNS depressants are present, such as in the immediate postoperative period, the dose should be limited to the minimum required.
The FDA drug label does not provide specific recommendations for weaning off Suboxone prior to surgery. It advises healthcare professionals to use the lowest effective dosage for the shortest duration of time consistent with individual patient treatment goals and to limit the dose to the minimum required in high-risk patients, such as those in the immediate postoperative period 2.
From the Research
Current Recommendations for Weaning Off Suboxone Prior to Surgery
- The current recommendations suggest that buprenorphine, the active ingredient in Suboxone, should not be routinely discontinued in the perioperative setting to decrease the risk of opioid use disorder (OUD) recurrence 3.
- Instead, a multimodal analgesic strategy, including simultaneous administration of buprenorphine and full agonist opioid (FAO) analgesics, nonopioid adjuncts such as acetaminophen and nonsteroidal anti-inflammatory drugs, and regional anesthesia, is recommended as a safe and effective perioperative strategy for patients prescribed long-term buprenorphine treatment of OUD 4.
- Maintaining buprenorphine perioperatively does not lead to worsened clinical outcomes, and patients can receive adequate pain control from mu-opioid agonists while maintained on buprenorphine 5.
Management of Suboxone in Emergent Surgery
- In cases of emergent surgery, the priority is to ensure maternal safety, maintain the pregnancy, and ensure fetal well-being 6.
- The choice of anesthetic technique and the selection of appropriate anesthetic drugs should be guided by the indication for surgery, the nature of the surgery, and the site of the surgical procedure 6.
- Buprenorphine can be continued at a reduced dose when indicated to avoid withdrawal symptoms and to facilitate the analgesic efficacy of mu-opioid agonists administered in combination for acute postoperative pain 5.
Key Considerations
- A multi-modal analgesic approach should be used to achieve sufficient analgesia in patients with OUD treated with buprenorphine 7.
- Care coordination and discharge planning are crucial when making an analgesic plan for patients with OUD treated with buprenorphine 7.
- An individualized approach founded upon shared decision-making should be used to manage patients with OUD treated with buprenorphine in the perioperative period 7.