When to resume Suboxone (buprenorphine) post-operatively?

From the Guidelines

Resuming Suboxone (buprenorphine/naloxone) after surgery should typically occur once acute postoperative pain has improved and the need for full opioid agonists has decreased, usually within 24-72 hours after surgery, as recommended by the most recent guidelines 1. The decision to resume Suboxone should be individualized based on the patient's specific circumstances, including the dose and indication for buprenorphine treatment, risk of relapse, and expected level of postsurgical pain. Key considerations include:

• Starting with the regular prescribed dose of Suboxone, but considering beginning with half the usual dose to assess tolerance 1.
• Waiting at least 12-24 hours after the last dose of full opioid pain medication before restarting Suboxone to avoid precipitated withdrawal 1.
• Coordinating the transition with both the surgeon and the provider who prescribes Suboxone to ensure proper pain management 1.
• Being aware of the potential for withdrawal symptoms when restarting Suboxone and contacting the healthcare provider immediately if they occur 1.
• Understanding that once Suboxone is restarted, other opioid pain medications will have limited effectiveness due to the blocking effect of buprenorphine, making the transition timing crucial for effective pain control during recovery 1. It is also important to note that the quality of evidence regarding perioperative management of patients on buprenorphine is weak, and more high-quality research is needed in this area 1. However, the available evidence suggests that continuing buprenorphine therapy in the perioperative period is generally recommended, with some guidelines suggesting that it is rarely appropriate to reduce the dose, irrespective of the indication or formulation 1.

From the Research

Perioperative Management of Suboxone

The decision to resume Suboxone (buprenorphine) post-operatively is complex and depends on several factors, including the type of surgery, patient characteristics, and formulation of buprenorphine.

• Studies have shown that continuing buprenorphine therapy perioperatively may be associated with reduced postoperative opioid requirements 2.
• However, other studies have found that holding buprenorphine therapy preoperatively may not significantly affect postoperative opioid use 3.
• A retrospective study found that patients who continued buprenorphine preoperatively had a significantly lower postoperative opioid requirement, and were more likely to be younger and female 2.
• Another study found that buprenorphine was restarted postoperatively for 52% of patients, and held for 48% postoperatively, with no significant difference in postoperative opioid use between the two groups 2.

Factors to Consider

When deciding whether to resume Suboxone post-operatively, the following factors should be considered:

• The nature of the surgery and postoperative opioid requirement
• Patient characteristics, such as age and gender
• Formulation of buprenorphine and indication for therapy
• Social support and patient motivation
• Non-opioid adjuvant therapy options
• Studies have shown that holding buprenorphine perioperatively does not align with emerging clinical recommendations and carries significant risks, including overdose and death 4.

Clinical Recommendations

While there is no consensus on optimal management, clinical recommendations suggest that buprenorphine therapy should be continued perioperatively, with careful monitoring of postoperative opioid requirements 5, 2.

• A study found that high rates of perioperative buprenorphine dose holds were observed, and that educational campaigns or other provider-targeted interventions may be needed to ensure patients with OUD receive recommended care 4.