When should a buprenorphine (opioid partial agonist) patch be removed before Coronary Artery Bypass Graft (CABG) surgery?

Buprenorphine Patch Management Before CABG

For buprenorphine patches used for opioid use disorder (OUD), continue the patch throughout the perioperative period; for patches used for chronic pain management, the patch can be continued or discontinued based on expected postoperative pain severity, but continuation is increasingly favored to reduce opioid requirements and prevent withdrawal. 1, 2

Key Distinction: Indication Matters

The management of buprenorphine patches before CABG fundamentally differs based on whether the patient is using it for opioid use disorder versus chronic pain:

For Opioid Use Disorder (OUD)

• Continue buprenorphine patches throughout the perioperative period without interruption 1
• The 2019 PAIN (Perioperative Pain and Addiction Interdisciplinary Network) clinical practice advisory reached consensus that buprenorphine for OUD should be maintained to prevent relapse risk, which outweighs bleeding concerns 1
• No specific timing for removal is recommended - the patch stays on 1

For Chronic Pain Management

• Two acceptable strategies exist, with recent evidence favoring continuation:
  • Continue the patch (increasingly preferred approach) 1, 2
  • Discontinue 72 hours before surgery if planning to use full opioid agonists exclusively 1

Evidence Supporting Continuation

Recent research demonstrates significant advantages to continuing buprenorphine:

• Patients who continued buprenorphine preoperatively had significantly lower postoperative opioid requirements compared to those who discontinued it 2
• Continuation was associated with fewer inpatient pain service consultations 2
• The mean discontinuation time in patients who stopped buprenorphine was 3.5 days before surgery, but this approach resulted in higher opioid consumption 2

Critical Management Principles

If Continuing Buprenorphine (Recommended Approach):

• Maintain current patch dosing throughout the perioperative period 1
• For patients on doses ≤12 mg sublingual equivalent, continuation is strongly supported 1
• For higher doses, consider tapering to 12 mg sublingual equivalent 2-3 days preoperatively 1
• Use higher-than-normal doses of full opioid agonists for breakthrough pain, as buprenorphine's partial agonist properties will require dose escalation 1
• Implement aggressive multimodal analgesia including regional techniques, NSAIDs, acetaminophen, ketamine, and gabapentinoids 1

If Discontinuing Buprenorphine:

• Remove patch 72 hours (3 days) before surgery to allow washout 1
• This timing allows buprenorphine levels to decrease sufficiently for full opioid agonists to be effective 1
• Establish a clear plan for reinitiation postoperatively with the patient's buprenorphine provider 1
• Consider transitioning to methadone preoperatively if relapse risk is high 1

Comparison to Other Antiplatelet Agents (Context)

While the guidelines extensively address antiplatelet medication timing before CABG, buprenorphine is not mentioned in traditional CABG guidelines 1:

• Clopidogrel: discontinue 5-7 days before elective CABG 1, 3
• Prasugrel: discontinue 7 days before elective CABG 1, 3
• Ticagrelor: discontinue 5 days before elective CABG 1, 3

This absence from CABG guidelines reflects that buprenorphine management is driven by addiction medicine and pain management principles, not bleeding risk.

Common Pitfalls to Avoid

• Do not abruptly discontinue buprenorphine in OUD patients - this dramatically increases relapse risk and is contraindicated 1
• Do not assume standard opioid doses will be effective if continuing buprenorphine - expect to use 2-4 times normal doses for breakthrough pain 1
• Do not fail to coordinate with the patient's buprenorphine prescriber - involve them early in perioperative planning 1
• Do not neglect multimodal analgesia - this is the cornerstone of successful perioperative management regardless of buprenorphine strategy 1

Postoperative Considerations

• If buprenorphine was continued, maintain the patch and add full agonist opioids as needed for 2-4 days post-surgery 1
• If buprenorphine was discontinued, restart once acute pain requiring narcotic analgesics has resolved 1
• Expect a longer-than-normal pain management course in the postoperative period 1
• Nearly 10% of opioid-naive cardiac surgery patients develop persistent opioid use, emphasizing the importance of appropriate buprenorphine management in patients already on therapy 4