Management of Patients on Suboxone Undergoing Cystoscopy
Continue Suboxone at the current dose for patients undergoing cystoscopy, as diagnostic cystoscopy requires minimal to no opioid analgesia and discontinuing buprenorphine creates unnecessary risks of withdrawal and relapse. 1, 2, 3
Procedural Context and Pain Expectations
Diagnostic cystoscopy is a minimally painful procedure with median pain scores of 2.82 during passage through the membranous urethra and 0.14-0.84 for other portions of the examination, making it well-tolerated without systemic opioid analgesia 4
Expert consensus recommends 0 opioid tablets (minimum and maximum) for diagnostic cystoscopy in the general population, emphasizing that nonopioid pain management is appropriate and typically sufficient 1
Cystoscopy has minimal impact on quality of life with an overall complication rate of only 15% (primarily mild urethrorrhagia and dysuria), and no patients requiring hospitalization in observational studies 5
Buprenorphine Management Strategy
Maintain the patient's current Suboxone dose throughout the periprocedural period rather than discontinuing or tapering, as this prevents withdrawal symptoms, maintains opioid use disorder treatment continuity, and avoids increased relapse risk 2, 3
Key Rationale for Continuation:
Buprenorphine can be safely continued during procedures according to the Society for Perioperative Assessment and Quality Improvement, particularly for patients being treated for opioid use disorder 3
Discontinuing buprenorphine unnecessarily leads to withdrawal symptoms, increased pain sensitivity, and dramatically increased relapse risk with associated overdose mortality 6, 2, 3
The minimal pain associated with cystoscopy does not justify the risks of buprenorphine discontinuation, as local anesthesia with lidocaine gel provides adequate analgesia for most patients 4
Sedation Considerations
Inform the proceduralist and anesthesia team about the patient's Suboxone use to allow for appropriate sedation planning, though standard sedation protocols with benzodiazepines (midazolam) remain effective 3, 7
Sedation Management:
Midazolam is superior to diazepam for intravenous sedation during cystoscopy, providing better sedation, decreased pain perception, and reduced procedure recall 7
Buprenorphine does not block the action of benzodiazepines or other sedatives, so standard conscious sedation protocols can be used without modification 3
Full mu-opioid agonists (such as fentanyl) can still be effective when used alongside buprenorphine if additional analgesia is needed, though this is rarely necessary for diagnostic cystoscopy 2, 3
Avoid using naloxone for reversal as it will precipitate acute opioid withdrawal in patients on Suboxone maintenance therapy 1
Periprocedural Pain Management Algorithm
Use a stepwise approach prioritizing nonopioid analgesics:
Continue Suboxone at the current dose without interruption 2, 3
Administer local anesthesia with lidocaine gel (2% intraurethral) as standard of care for cystoscopy 4
Provide scheduled nonopioid analgesics including acetaminophen 1,000 mg every 6 hours and ibuprofen 800 mg every 8 hours in staggered fashion for post-procedure discomfort, unless contraindicated 1
Use midazolam for procedural sedation if needed, with standard dosing (1 mg initial dose in adults <60 years, titrated by 1 mg every 2 minutes to effect) 1, 7
Reserve additional opioid analgesia only for unexpected severe pain, recognizing that higher-than-typical doses (1.5-2 times standard) may be needed due to buprenorphine's receptor occupancy 2
Critical Safety Considerations
Never abruptly discontinue Suboxone for cystoscopy, as this constitutes unacceptable medical care with significant morbidity and mortality risks comparable to abruptly stopping antihypertensives 6
Specific Warnings:
Avoid mixed agonist-antagonist opioids (such as pentazocine or butorphanol) as they will precipitate acute withdrawal in patients on Suboxone 2
Coordinate with the patient's Suboxone prescriber regarding verification of current dose and notification of any controlled substances administered during the procedure 2
Monitor for drug interactions including QT prolongation if using other medications with similar effects 2, 3
Common Pitfalls to Avoid
Do not assume that patients on Suboxone require opioid discontinuation before minor procedures—this outdated approach increases harm without benefit 3
Do not rely on Suboxone to provide analgesia for acute procedural pain, as buprenorphine maintenance therapy provides minimal to no analgesia for acute pain 2
Do not perform "cold referrals" or abandon patients by refusing to continue Suboxone during the periprocedural period, as this constitutes patient abandonment 6
Do not withhold appropriate sedation based on concerns about buprenorphine interactions—benzodiazepines and other sedatives work normally in patients on Suboxone 3, 7