From the Guidelines
For post-operative pain management in a patient on buprenorphine/naloxone 16 mg daily for 5 years undergoing major surgery, the best approach is to continue the buprenorphine throughout the perioperative period while supplementing with multimodal analgesia. The patient should take their usual buprenorphine dose on the day of surgery and resume their regular schedule postoperatively. For breakthrough pain, use full mu-opioid agonists at higher doses (such as hydromorphone 2-4 mg IV every 2-3 hours as needed or fentanyl 50-100 mcg IV every 1-2 hours) to overcome buprenorphine's high receptor affinity, as suggested by 1. Implement a comprehensive multimodal regimen including:
- Scheduled acetaminophen 1000 mg every 6 hours
- NSAIDs like ketorolac 15-30 mg IV every 6 hours (if not contraindicated)
- Gabapentinoids
- Ketamine infusion (0.1-0.2 mg/kg/hr)
- Regional anesthesia techniques when applicable This approach works because continuing buprenorphine maintains baseline opioid tolerance and prevents withdrawal while allowing supplemental opioids to provide additional analgesia by binding to unoccupied receptors, as noted in 1. Close monitoring in a setting with expertise in pain management is essential, with frequent reassessment and dose adjustments as needed. Early consultation with pain specialists and addiction medicine is recommended to optimize the pain management strategy. The use of non-drug strategies, non-opioid options, and multimodal analgesia is supported by various studies, including those by Lembke and colleagues 1 and Harrison and colleagues 1, which emphasize the importance of a comprehensive approach to pain management in patients on chronic opioid therapy. Therefore, option C is the most appropriate choice, as it recommends using non-drug and non-opioid options first, then additional opioids if needed, and acknowledges that the patient may need higher doses of opioids due to tolerance and increased sensitivity to pain.
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.