What are the treatment options for perioperative pain management in patients undergoing buprenorphine (opioid partial agonist) therapy for opioid dependency?

From the Guidelines

For perioperative pain management in patients on buprenorphine therapy for dependency, the recommended strategy is to continue buprenorphine therapy in the perioperative period, as suggested by the most recent and highest quality study 1. The approach depends on the expected pain severity and surgery duration. For minor procedures with minimal pain, continuing the patient's regular buprenorphine dose is appropriate while supplementing with non-opioid analgesics like acetaminophen (1000 mg every 6 hours), NSAIDs such as ketorolfen (15-30 mg IV every 6 hours), and regional anesthesia techniques when possible. Some key considerations include:

• The prescribed daily dose of buprenorphine
• Indication for buprenorphine treatment (pain vs dependency)
• Risk of relapse
• Expected level of postsurgical pain For moderate to severe pain, options include continuing buprenorphine while using higher doses of full μ-opioid agonists to overcome buprenorphine's high receptor affinity, as recommended by 1. Multimodal analgesia is essential in all cases, incorporating ketamine infusions (0.1-0.2 mg/kg/hr), gabapentinoids, and dexmedetomidine. The challenge with buprenorphine is its high affinity for μ-opioid receptors and partial agonist activity, which creates a ceiling effect and can block other opioids. After surgery, patients should be restarted on their maintenance buprenorphine dose once acute pain resolves, with careful monitoring for withdrawal symptoms and pain control, as suggested by 1. It is also important to consider the potential for drug-drug interactions, particularly with QT-prolonging agents, which are contraindicated with buprenorphine, as noted in 1. Overall, the goal is to provide effective pain management while minimizing the risk of relapse and ensuring the patient's safety and well-being.

From the FDA Drug Label

Buprenorphine hydrochloride injection is indicated for the management of pain severe enough to require an opioid analgesic and for which alternate treatments are inadequate Limitations of Use: ... reserve buprenorphine hydrochloride for use in patients for whom alternative treatment options (e.g., non-opioid analgesics or opioid combination products): • Have not been tolerated or are not expected to be tolerated, • Have not provided adequate analgesia or are not expected to provide adequate analgesia

The treatment options for perioperative pain management in the setting of buprenorphine therapy for dependency are not explicitly stated in the provided drug label. However, based on the information given, it can be inferred that:

• Non-opioid analgesics may be considered as an alternative treatment option.
• Opioid combination products may also be considered as an alternative treatment option. It is essential to note that the label does not provide direct guidance on perioperative pain management in patients undergoing buprenorphine therapy for dependency 2.

From the Research

Perioperative Pain Management in Buprenorphine Therapy

The management of perioperative pain in patients undergoing surgery or interventional pain procedures while on buprenorphine therapy for dependency involves several considerations.

• The nature of the surgery, postoperative opioid requirement, and patient characteristics must be taken into account when devising a plan 3.
• Options for perioperative management include continuing buprenorphine therapy or holding it for a defined period with or without bridging to alternative opioids 3.
• A multidisciplinary approach, including social support and nonopioid adjuvant therapy, is recommended to optimize pain management and minimize the risk of relapse 4, 5.

Treatment Strategies

Different treatment strategies can be employed, including:

• Continuing buprenorphine therapy, especially when the dose is < 16 mg sublingually daily, as observational studies indicate no evidence against this approach 6.
• Using a multimodal analgesic strategy, including simultaneous administration of buprenorphine and full agonist opioid, nonopioid adjuncts, and regional anesthesia 5.
• Considering the unique aspects of buprenorphine formulations and dosing, as well as the importance of patient motivation and social support 4.

Key Considerations

Key considerations in perioperative pain management for patients on buprenorphine therapy include:

• The potential for relapse, particularly in patients with a recent history of opioid use disorder 6.
• The need for standardized reporting of median doses, dosing schedules, and rates of addiction relapse 6.
• The importance of a strong rationale supported by patient and surgical preferences when discontinuing buprenorphine perioperatively 6.
• The role of nonopioid adjuvant therapy and regional anesthesia in optimizing pain management 5.