What should be added to the treatment regimen for a patient undergoing gallbladder surgery who is a regular heroin user and being started on the Clinical Opiate Withdrawal Scale (COWS) protocol?

Perioperative Management of Heroin User Undergoing Gallbladder Surgery with COWS Protocol

Buprenorphine should be added to the treatment regimen for this patient, initiated when COWS score reaches ≥8 (moderate withdrawal), with a starting dose of 4-8 mg sublingual, while continuing the medication perioperatively through surgery and discharge. 1

Immediate Preoperative Management

Buprenorphine Initiation Protocol

• Confirm adequate time since last heroin use (minimum 12 hours for short-acting opioids like heroin) before administering buprenorphine to avoid precipitated withdrawal 1, 2
• Assess withdrawal severity using COWS: Only initiate buprenorphine when COWS score ≥8 (moderate withdrawal); no buprenorphine is indicated if COWS <8 1
• Initial dosing: Administer 4-8 mg sublingual buprenorphine based on withdrawal severity, reassess after 30-60 minutes 1
• Target dose: Aim for 16 mg sublingual total on day 1 for most patients, which can be achieved through incremental dosing 1, 2

Critical Timing Considerations

The COWS protocol alone is insufficient—it only monitors withdrawal but doesn't treat the underlying opioid use disorder or prevent relapse. 1 Heroin has a short half-life (2-4 hours), so withdrawal symptoms typically appear within 12-24 hours of last use, making this patient an ideal candidate for rapid buprenorphine induction. 3

Perioperative Buprenorphine Management

Continue Buprenorphine Through Surgery

It is almost always appropriate to continue buprenorphine at the preoperative dose through the perioperative period. 1 This recommendation is based on expert consensus that prioritizes preventing relapse and maintaining opioid use disorder treatment continuity. 1

• Do not discontinue buprenorphine before gallbladder surgery—older recommendations to stop buprenorphine 72 hours preoperatively are outdated and increase relapse risk 1
• Maintain the established dose (likely 16 mg daily from induction) through the day of surgery 1
• Involve the inpatient pain service in postoperative care planning for this opioid-tolerant patient 1

Multimodal Analgesia Strategy

Buprenorphine's partial mu-opioid agonist activity creates competitive receptor blockade, requiring aggressive multimodal pain management: 1, 4

• Regional anesthesia techniques should be utilized when possible for gallbladder surgery (e.g., transversus abdominis plane blocks, local anesthetic infiltration) 1, 4
• Non-opioid adjuncts: NSAIDs, acetaminophen, ketamine, and gabapentinoids as appropriate 1
• Full mu-opioid agonists at 2-4 times typical doses may be necessary for breakthrough pain due to buprenorphine's receptor occupancy 1, 4
• Divided dosing: Consider administering buprenorphine every 6-8 hours rather than once daily to provide more consistent analgesia 1, 4

Postoperative Pain Management

Ward-Based Care

• Use immediate-release opioids (oral morphine 10 mg/5 mL preferred) for breakthrough pain when simple analgesics are insufficient 1
• Avoid modified-release opioid preparations including transdermal patches, as they are associated with harm in the acute postoperative setting 1
• Monitor sedation scores in addition to respiratory rate to detect opioid-induced ventilatory impairment 1
• Expect higher opioid requirements: This patient will require substantially more full agonist opioids than typical patients due to buprenorphine's partial agonist effects 1, 4

Reverse Analgesic Ladder

When pain improves, follow this specific sequence: 1

1. Wean full agonist opioids first
2. Then stop NSAIDs
3. Finally stop acetaminophen
4. Continue buprenorphine throughout and after discharge

Discharge Planning

Buprenorphine Continuation

• Discharge on buprenorphine 16 mg sublingual daily (or the established maintenance dose) 1, 2
• Prescribe 5-7 days maximum of immediate-release opioids for surgical pain (not modified-release formulations) 1
• Separate prescriptions: Write opioid and non-opioid analgesics as separate prescriptions to allow independent dose adjustments 1
• Explicit discharge instructions: The discharge letter must state the exact opioid dose, amount supplied, and planned duration to prevent inadvertent repeat prescriptions 1

Addiction Treatment Linkage

This is the most critical addition beyond the COWS protocol: 1

• Arrange outpatient buprenorphine provider follow-up within 3-7 days of discharge 1
• Provide overdose prevention education and take-home naloxone kit 1
• Offer hepatitis C and HIV screening 1
• Coordinate with addiction medicine or outpatient buprenorphine prescriber before discharge 1

Common Pitfalls to Avoid

Precipitated Withdrawal Risk

• Never administer buprenorphine until objective signs of moderate withdrawal appear (COWS ≥8) 1, 2, 5
• A COWS increase of ≥6 points within 60 minutes indicates precipitated withdrawal 5
• Only 3.2% of patients with COWS 4-7 experience precipitated withdrawal, compared to 13.5% with COWS 0-3 6

Inadequate Pain Control

The most common error is underestimating postoperative opioid requirements in buprenorphine-maintained patients. 1, 4 Expect to use 2-4 times the typical full agonist opioid doses for 2-4 days post-surgery. 1, 4

Relapse Prevention Failure

Discontinuing buprenorphine perioperatively dramatically increases relapse risk and mortality. 1 The outdated practice of stopping buprenorphine 72 hours before surgery has been replaced by continuation strategies that prioritize addiction treatment continuity. 1

Monitoring Requirements

• Sedation scores must be documented alongside respiratory rate, as respiratory depression can occur before rate changes 1
• Pain intensity increases may indicate surgical complications (compartment syndrome, anastomotic leak) rather than inadequate analgesia 1
• Persistent opioid use >90 days postoperatively warrants evaluation for chronic post-surgical pain 1

Summary Algorithm

1. Admission: Assess time since last heroin use (>12 hours required) 1, 2
2. COWS monitoring: Score every 1-2 hours until ≥8 1
3. Buprenorphine induction: 4-8 mg sublingual when COWS ≥8, target 16 mg day 1 1
4. Perioperative: Continue buprenorphine through surgery 1
5. Postoperative: Multimodal analgesia + higher-dose full agonists as needed 1, 4
6. Discharge: Buprenorphine continuation + ≤7 days immediate-release opioids + addiction treatment linkage 1