From the Guidelines
Patients taking Suboxone (buprenorphine/naloxone) should be managed on a case-by-case basis, with consideration of continuing the medication through the perioperative period to maintain opioid dependence treatment and prevent withdrawal, as recommended by the Society for Perioperative Assessment and Quality Improvement (SPAQI) consensus statement 1. When considering anesthesia for patients on Suboxone, several factors must be taken into account, including:
- The prescribed daily dose of buprenorphine
- The indication for buprenorphine treatment (pain vs dependency)
- The risk of relapse
- The expected level of postsurgical pain According to the SPAQI consensus statement, the decision to continue or hold buprenorphine should be individualized to the patient and clinical circumstances 1. It is also important to note that concomitant use of buprenorphine and QT-prolonging agents is contraindicated, and multiple drug-drug interactions resulting in QT-interval prolongation, serotonin syndrome, paralytic ileus, reduced analgesic effect, or precipitation of withdrawal symptoms are possible 1. For minor procedures, local anesthetics and non-opioid pain medications like acetaminophen, NSAIDs, and ketamine may be sufficient, while for major surgeries requiring opioids, higher doses may be needed as Suboxone partially blocks opioid receptors. After surgery, patients should resume their regular Suboxone dosing as directed by their prescribing physician, typically once opioid pain medications are no longer needed, to minimize the risk of withdrawal and ensure continuity of care.
From the FDA Drug Label
Examples: Benzodiazepines and other sedatives/hypnotics, anxiolytics, tranquilizers, muscle relaxants, general anesthetics, antipsychotics, and other opioids, alcohol Buprenorphine may enhance the neuromuscular blocking action of skeletal muscle relaxants and produce an increased degree of respiratory depression There is increased risk in patients whose ability to maintain blood pressure has already been compromised by a reduced blood volume, or concurrent administration of certain CNS depressant drugs (e.g., phenothiazines or general anesthetics)
The use of Suboxone (buprenorphine and naloxone) with anesthesia should be approached with caution due to the potential for:
- Increased risk of respiratory depression
- Enhanced neuromuscular blocking action of skeletal muscle relaxants
- Increased risk of hypotension, including orthostatic hypotension and syncope, in patients whose ability to maintain blood pressure has already been compromised. It is recommended to carefully monitor patients for signs of respiratory depression, sedation, and hypotension when using Suboxone with anesthesia 2.
From the Research
Considerations for Using Suboxone with Anesthesia
When considering the use of Suboxone (buprenorphine and naloxone) with anesthesia, several factors must be taken into account.
- Reversal of Respiratory Depression: Naloxone is commonly used to reverse opioid-induced respiratory depression, but it has a short half-life and may precipitate withdrawal in dependent patients 3, 4. Buprenorphine, on the other hand, has a longer duration of action and may be a safer alternative for reversing respiratory depression in some cases 3.
- Dosing and Administration: The dosage and administration of naloxone and buprenorphine are critical in reversing respiratory depression. Higher doses of naloxone may be required to reverse synthetic opioid overdoses, but this may also increase the risk of severe withdrawal symptoms or pulmonary edema 4. Buprenorphine dosing strategies must be carefully considered to maintain reversal of respiratory depression without precipitating withdrawal 3, 5.
- Patient Characteristics: Certain patient characteristics, such as obstructive sleep apnea and adverse respiratory events in the recovery room, may increase the risk of respiratory depression or sedation requiring naloxone intervention 6.
- Interactions with Other Medications: Buprenorphine may interact with other medications, such as benzodiazepines, to cause severe respiratory depression 7. The exact mechanism of this interaction is unclear, but it is thought to involve a pharmacodynamic interaction.
- Monitoring and Management: Patients receiving Suboxone with anesthesia require careful monitoring and management to prevent respiratory depression or sedation. This may involve close observation in the post-anesthesia care unit, careful titration of opioid doses, and the use of naloxone or other reversal agents as needed 6, 5.