What are the considerations for using buprenorphine and methadone in surgical patients?

From the Guidelines

Buprenorphine and methadone should generally be continued throughout the perioperative period in surgical patients who are on these medications for opioid use disorder or chronic pain. For patients on buprenorphine, maintaining their usual dose is recommended as it provides partial analgesia and prevents withdrawal, as suggested by the Perioperative Pain and Addiction Interdisciplinary Network 1. Higher doses of full mu-opioid agonists may be needed for breakthrough pain due to buprenorphine's high receptor affinity. For patients on methadone, continue their regular dose and supplement with additional short-acting opioids for surgical pain as needed. If NPO status prevents oral administration, buprenorphine can be given sublingually, while methadone may require temporary conversion to parenteral administration (typically at 50-75% of the oral dose) 1. Close coordination between the surgical team, pain specialists, and addiction medicine providers is essential. Regional anesthesia techniques and multimodal analgesia (including NSAIDs, acetaminophen, gabapentinoids, and ketamine) should be maximized to reduce opioid requirements. The rationale for continuing these medications is to maintain opioid tolerance, prevent withdrawal symptoms, and reduce the risk of relapse in patients with opioid use disorder, while still providing adequate pain control through adjunctive measures.

Some key considerations for the perioperative management of buprenorphine include:

• Continuing buprenorphine therapy in the perioperative period, as it is rarely appropriate to reduce the dose, irrespective of the indication or formulation 1
• Tapering buprenorphine to 12 mg daily over 2 to 3 days preoperatively for higher doses (>12 mg daily) often prescribed for the treatment of opioid use disorders 1
• Using full mu agonists (e.g., morphine, fentanyl, oxycodone, hydromorphone) for breakthrough pain while maintaining buprenorphine therapy 1
• Maximizing regional anesthesia techniques and multimodal analgesia to reduce opioid requirements 1

Overall, the goal of perioperative management of buprenorphine and methadone is to provide adequate pain control while minimizing the risk of relapse and withdrawal symptoms in patients with opioid use disorder. By continuing these medications and using adjunctive therapies, healthcare providers can optimize patient outcomes and reduce the risk of morbidity and mortality.

From the FDA Drug Label

Methadone Hydrochloride Oral Concentrate should be administered with extreme caution to patients with conditions accompanied by hypoxia, hypercapnia, or decreased respiratory reserve such as: asthma, chronic obstructive pulmonary disease or cor pulmonale, severe obesity, sleep apnea syndrome, myxedema, kyphoscoliosis, and CNS depression or coma In these patients, even usual therapeutic doses of methadone may decrease respiratory drive while simultaneously increasing airway resistance to the point of apnea. Many acute pain conditions (e.g., the pain that occurs with a number of surgical procedures or acute musculoskeletal injuries) require no more than a few days of an opioid analgesic. 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.

Considerations for using buprenorphine and methadone in surgical patients:

• Caution with respiratory depression: Methadone and buprenorphine can cause respiratory depression, especially in patients with conditions accompanied by hypoxia, hypercapnia, or decreased respiratory reserve.
• Dose limitation: In high-risk patients, such as the elderly, debilitated, or those with respiratory disease, the dose of buprenorphine and methadone should be limited to the minimum required.
• Monitoring: Patients receiving buprenorphine and methadone should be closely monitored for signs of respiratory depression, especially in the postoperative period.
• Alternative analgesics: Alternative, non-opioid analgesics should be considered in patients at risk of respiratory depression or other complications. 2 3 3

From the Research

Considerations for Buprenorphine and Methadone in Surgical Patients

• The continuation of buprenorphine and methadone during the perioperative period is generally recommended to reduce the risk of opioid withdrawal, relapse, or inadequately controlled pain 4.
• Buprenorphine itself has high analgesic potency, and discontinuing it may lead to suboptimal pain control and risk for opioid use disorder relapse 5.
• Studies have shown that continuing buprenorphine perioperatively can lead to lower nonbuprenorphine opioid requirements and similar levels of analgesia compared to holding buprenorphine 5, 6.
• Methadone should also be continued perioperatively, as it is generally agreed that this is the best course of action 4, 6.
• The optimal management of patients with opioid use disorder in the settings of acute pain is challenging, and recovery can be jeopardized secondary to the unique pharmacology of these agents 7.
• Providers need to have an in-depth understanding of how to manage buprenorphine, methadone, and other medications for opioid use disorder in the perioperative setting to provide optimal pain control and minimize the risk of relapse and overdose 8.

Perioperative Management

• Patients who continue buprenorphine in the first 48 hours postoperatively may require half the dose of nonbuprenorphine opioids compared to those who have buprenorphine held 5.
• Nearly all patients who continue buprenorphine in the first 48 hours postoperatively are discharged on this agent, while only half of patients who have buprenorphine held are restarted on it at discharge 5.
• There are no significant differences in pain scores, incidence of nausea or vomiting requiring treatment, or sedation between patients taking buprenorphine or methadone opioid substitution therapy 6.