What is the recommended approach for postoperative pain relief with buprenorphine (Bup), using a regular regimen with as-needed doses versus as-needed doses only?

Regular vs As-Needed Buprenorphine for Postoperative Pain Management

For patients on buprenorphine therapy undergoing surgery, continuing the regular preoperative buprenorphine regimen with supplemental as-needed opioids is strongly recommended over using only as-needed dosing, as this approach reduces the risk of both pain disorder exacerbation and opioid use disorder relapse. 1

Rationale for Continuing Regular Buprenorphine Dosing

The 2019 PAIN Clinical Practice Advisory provides clear guidance that maintaining patients on their regular buprenorphine regimen throughout the perioperative period is the preferred approach for most patients 1. This recommendation is based on several key considerations:

• Preventing OUD Relapse: Discontinuing or switching to PRN-only dosing increases the risk of destabilizing patients with opioid use disorder (OUD)
• Maintaining Pain Control: Regular dosing provides baseline analgesia for chronic pain patients
• Respiratory Safety: Buprenorphine's ceiling effect on respiratory depression offers a safety advantage

Evidence Quality Assessment

The evidence supporting this recommendation is primarily Level 5 (case series and expert consensus), but represents the most current clinical practice advisory from a multidisciplinary expert panel 1.

Perioperative Management Algorithm

Preoperative Phase

• Continue regular buprenorphine dosing at the preoperative dose through surgery 1
• For patients on higher doses (>12mg SL daily), some experts suggest tapering to 12mg SL 2-3 days before surgery, but continuing regular dosing is still preferred 1
• Do NOT discontinue buprenorphine 72 hours before surgery as previously recommended in older guidelines 1

Intraoperative Phase

• Implement multimodal analgesia
• Utilize regional anesthesia techniques when possible 1
• Anticipate potentially higher opioid requirements

Postoperative Phase

1. Continue regular buprenorphine dosing schedule 1
2. Implement multimodal analgesia with non-opioid adjuncts:
   • NSAIDs
   • Acetaminophen
   • Gabapentin/pregabalin
   • Ketamine
   • Dexmedetomidine
   • Lidocaine
3. Add as-needed full mu-opioid agonists (fentanyl, hydromorphone, morphine) for breakthrough pain 1
4. Important: Higher than normal doses of full mu-agonists may be required for adequate analgesia 1, 2

Special Considerations

Dosing Challenges

• Patients on buprenorphine require significantly higher doses of conventional opioids for breakthrough pain control 2
• One study found patients on transdermal buprenorphine required approximately twice the amount of IV morphine equivalents compared to opioid-naive patients (98mg vs 46mg) 2
• Higher preoperative buprenorphine doses correlate with greater postoperative opioid requirements 2

Common Pitfalls to Avoid

1. Discontinuing buprenorphine before surgery: This outdated approach increases risk of OUD relapse and does not improve pain control 1
2. Inadequate dosing of breakthrough opioids: Patients may require higher than standard doses of full mu-agonists 1, 2
3. Insufficient multimodal analgesia: Regional techniques and non-opioid adjuncts are crucial components 1
4. Poor discharge planning: Failure to coordinate with outpatient buprenorphine providers increases risk of relapse 1

Monitoring Requirements

• More intensive monitoring may be required when adding full mu-agonists to buprenorphine therapy
• Consider longer hospital admission for patients with complex pain needs 1
• Coordinate with addiction medicine or pain specialists for optimal management

In summary, the evidence strongly supports maintaining patients on their regular buprenorphine regimen throughout the perioperative period while supplementing with multimodal analgesia and as-needed full mu-agonist opioids for breakthrough pain. This approach optimizes both pain control and addiction management outcomes.