What is the best approach for post-operative pain management in a patient taking buprenorphine (Suboxone)/naloxone 16 mg daily for the past 5 years who is undergoing major surgery?

From the Guidelines

The best approach for post-operative pain management in a patient taking buprenorphine (Suboxone)/naloxone 16 mg daily for the past 5 years who is undergoing major surgery is to continue the buprenorphine throughout the perioperative period while adding multimodal analgesia. This approach is supported by recent studies, including one published in the British Journal of Anaesthesia in 2019 1, which suggests that continuation of buprenorphine depending on the preoperative dose and indication is a viable strategy. The patient's usual buprenorphine dose should be maintained and supplemented with scheduled non-opioid medications, including:

• Acetaminophen 1000 mg every 6 hours
• NSAIDs such as ketorolac 15-30 mg IV every 6 hours (transitioning to oral ibuprofen 600 mg every 6 hours)
• Gabapentinoids like gabapentin 300 mg three times daily For breakthrough pain, full mu-opioid agonists at higher doses should be used to overcome buprenorphine's high receptor affinity, such as:
• Hydromorphone 2-4 mg IV every 2-3 hours as needed
• Fentanyl 50-100 mcg IV every 1-2 hours Regional anesthesia techniques like nerve blocks or epidural analgesia should be employed when appropriate for the surgical site. This approach is also supported by a study published in the American Journal of Obstetrics and Gynecology in 2019 1, which highlights the importance of continuing medication-assisted treatment (MAT) and using multimodal analgesia for post-operative pain management in patients with opioid use disorder. The patient will likely require higher doses of full agonist opioids for breakthrough pain, and close monitoring for respiratory depression is essential. Consultation with pain management specialists and addiction medicine is recommended for complex cases. Key points to consider include:
• Continuing buprenorphine throughout the perioperative period to prevent withdrawal and provide some analgesia
• Using multimodal analgesia, including non-opioid medications and regional anesthesia techniques
• Employing full mu-opioid agonists at higher doses for breakthrough pain
• Monitoring for respiratory depression and adjusting the treatment plan as needed.

From the Research

Post-Operative Pain Management for Patient Taking Buprenorphine/Naloxone

• The patient, BH, is taking buprenorphine/naloxone 16 mg daily for the past 5 years and will require additional pain control post-op.
• The best approach for post-operative pain management in this patient is to use non-drug and non-opioid options first, then additional opioids if needed, as opioid tolerance and increased sensitivity to pain may require higher doses of opioids than an opioid naïve patient 2.
• Non-opioid medications, such as NSAIDs and acetaminophen, are effective in managing acute post-surgical pain and can reduce opioid consumption 3, 4, 5, 6.
• A multimodal analgesic approach, including preemptive pregabalin and intravenous ibuprofen, can generate lower pain scores in the postoperative period and reduce postoperative opioid consumption 3.
• The use of non-opioid analgesics, such as paracetamol, NSAIDs, and metamizol (dipyrone), can be effective in managing postoperative pain, but the selection of the most appropriate compound for an individual patient should be based on increasing data on these analgesics 4.
• Combination therapy using a small amount of opioid together with a non-opioid pain reliever has been shown to be effective and reduces opioid consumption 6.

Options for Post-Operative Pain Management

• Option B is incorrect because it suggests using lower doses of opioids than an opioid naïve patient, which may not be sufficient for a patient with opioid tolerance.
• Option D is incorrect because it suggests using hydrocodone 10 mg three times daily without considering the patient's opioid tolerance and potential need for higher doses or alternative pain management strategies.
• Option A is incorrect because it suggests using non-drug strategies only, which may not be sufficient for managing post-operative pain in a patient with opioid tolerance.