How long should a patient discontinue Butrans (buprenorphine) patch before elective surgery?

Butrans Patch Discontinuation Before Elective Surgery

For patients on low-dose Butrans (buprenorphine transdermal patch) for chronic pain, the patch should NOT be discontinued before elective surgery—continue it perioperatively at the current dose. 1, 2

Evidence-Based Recommendation

The Society for Perioperative Assessment and Quality Improvement (SPAQI) explicitly recommends individualizing management based on the prescribed daily dose, indication for treatment (pain vs. opioid use disorder), risk of relapse, and expected postoperative pain level—but the overwhelming consensus from current guidelines is to continue buprenorphine perioperatively rather than discontinue it. 1

Key Management Principles:

For Low-Dose Buprenorphine (Butrans patches ≤20 mcg/hour):

• Continue the patch unchanged through the perioperative period 2, 3
• These low doses used for pain management do not significantly interfere with perioperative opioid analgesia 1
• Discontinuation creates unnecessary risks of withdrawal, increased pain sensitivity, and inadequate pain control 2, 3

For Higher-Dose Buprenorphine (>12 mg sublingual daily equivalent):

• Still continue in most cases, though some practitioners may consider tapering to 12 mg daily over 2-3 days preoperatively if very high postoperative pain is anticipated 1, 2
• Note: Butrans patches at maximum dose (20 mcg/hour) deliver approximately 0.5 mg/day, which is well below the 12 mg threshold 4

Perioperative Pain Management Strategy

Multimodal analgesia is essential because buprenorphine's partial mu-opioid agonist activity creates competitive receptor blockade: 2

• Regional anesthesia techniques should be maximized (nerve blocks, epidurals, local infiltration) 2
• Non-opioid adjuncts including NSAIDs, acetaminophen, and ketamine 2
• Full mu-opioid agonists (morphine, fentanyl, hydromorphone) can still be effective when given alongside buprenorphine, though expect to need 2-4 times typical opioid requirements for breakthrough pain 2
• Consider dividing the maintenance dose to every 6-8 hours rather than once-weekly patch application for more consistent analgesia postoperatively 2

Critical Drug Interactions and Monitoring

Alert the anesthesiologist about buprenorphine use because: 1, 3

• Concomitant use with QT-prolonging agents is contraindicated 1
• Multiple drug-drug interactions possible including serotonin syndrome risk, paralytic ileus, and respiratory depression when combined with other CNS depressants 1
• The anesthesia team needs to plan for higher opioid dosing requirements and optimize multimodal strategies 2, 3

Common Pitfalls to Avoid

Do NOT discontinue buprenorphine unnecessarily: 2, 3

• Discontinuation precipitates withdrawal symptoms within 12-48 hours 5
• Creates increased pain sensitivity and hyperalgesia 2
• In patients with opioid use disorder (not typical for Butrans users, but important to note), discontinuation dramatically increases relapse risk 1, 2

Do NOT assume opioid analgesia won't work: 1

• At clinically relevant doses, buprenorphine does not completely block full mu-opioid agonists but rather acts synergistically 1
• Higher doses of full agonists can overcome any competitive blockade 2

Do NOT forget to coordinate postoperative follow-up: 2

• Ensure the patient's buprenorphine provider is aware of the surgery and perioperative plan 2
• Plan for adequate postoperative pain management before discharge 2