What is the recommended management of opioid use disorder (OUD) with buprenorphine (BUP)

Management of Opioid Use Disorder with Buprenorphine

Buprenorphine should be continued at the preoperative dose for patients with opioid use disorder (OUD), as discontinuation may destabilize patients and increase risk of relapse. 1

First-Line Treatment Approach

Buprenorphine is a first-line treatment for OUD that significantly reduces illicit opioid use by approximately 80%. The recommended approach includes:

• Initial dosing: Start with 4-8mg sublingually, targeting 16mg total first-day dose 2
• Maintenance dosing: Target 16-24mg daily for most patients, with evidence supporting doses up to 32mg for improved outcomes in certain patients 3
• Formulation options:
  • Sublingual tablets/films (most common)
  • Transdermal patches (primarily for pain management)
  • Weekly injectable formulations (newer option that may improve adherence) 4, 5

Perioperative Management

The Perioperative Pain and Addiction Interdisciplinary Network (PAIN) clinical practice advisory strongly recommends:

• Continue buprenorphine at the preoperative dose throughout the perioperative period 1
• Do not reduce or stop buprenorphine therapy before surgery, regardless of formulation or indication 1
• Use adjunct analgesics (NSAIDs, acetaminophen, ketamine, gabapentin/pregabalin, dexmedetomidine, lidocaine) for perioperative pain management 1
• Add full mu-opioid agonists (morphine, fentanyl, hydromorphone) if needed for breakthrough pain while maintaining buprenorphine 1

This approach prevents destabilization of OUD and reduces risk of relapse, which is a greater concern than potential challenges with acute pain management 1.

Monitoring and Maintenance

A structured monitoring approach is essential:

• Initial phase: Weekly visits until stabilized
• Maintenance phase: Monthly visits once stable
• Urine drug testing: Regular monitoring to verify adherence and detect non-prescribed substance use 2
• Prescription monitoring: Check state databases regularly

Special Considerations

Low-Dose Initiation Options

For patients not yet on buprenorphine, several initiation methods exist:

• Traditional initiation: Requires moderate withdrawal (COWS score ≥8) before first dose
• Low-dose initiation ("micro-induction"): Can be used without requiring full withdrawal, particularly beneficial for:
  • Patients with co-occurring pain (91.7% of cases)
  • Patients anxious about withdrawal (69.4%)
  • Those with history of precipitated withdrawal (9.7%)
  • Patients with opioid withdrawal intolerance (6.9%) 6

Safety Precautions

• Overdose risk: Prescribe naloxone and educate patients/families on its use, especially if benzodiazepines are co-prescribed 2, 7
• Drug interactions: Monitor for interactions with:
  • Benzodiazepines and other CNS depressants (increased risk of respiratory depression)
  • CYP3A4 inhibitors (macrolides, azole antifungals, protease inhibitors)
  • CYP3A4 inducers (rifampin, carbamazepine, phenytoin)
  • Serotonergic drugs (risk of serotonin syndrome) 7

Comprehensive Treatment Approach

Medication should be combined with:

• Behavioral therapies: Evidence-based counseling approaches
• Regular monitoring: Urine toxicology and prescription monitoring
• Mental health screening: Address co-occurring psychiatric conditions
• Support groups: Consider referral to peer support resources 2

Common Pitfalls to Avoid

1. Discontinuing buprenorphine perioperatively: This increases relapse risk and is not supported by evidence 1
2. Inadequate pain management: Failure to utilize multimodal analgesia alongside buprenorphine
3. Overlooking drug interactions: Particularly with benzodiazepines and other CNS depressants
4. Insufficient monitoring: Lack of regular urine drug testing and follow-up
5. Missing co-occurring conditions: Failure to screen for and address mental health disorders

Buprenorphine's partial agonist properties provide a ceiling effect on respiratory depression, making it safer than full opioid agonists while effectively treating OUD 2, 7.