What is the optimal postoperative analgesic plan for an adult with opioid use disorder on 6 mg buprenorphine/naloxone (Suboxone) daily undergoing oral surgery with bone grafts and mandibular bone smoothing?

Postoperative Pain Management for OUD Patient on 6 mg Suboxone After Oral Surgery

Continue the patient's 6 mg daily Suboxone unchanged throughout the perioperative period and add full mu-opioid agonists (hydrocodone or oxycodone) at higher-than-typical doses for breakthrough pain, combined with aggressive multimodal non-opioid analgesia. 1, 2

Core Management Strategy

Buprenorphine Continuation

• Maintain the baseline 6 mg Suboxone dose without interruption or tapering. 1, 2
• The Perioperative Pain and Addiction Interdisciplinary Network explicitly states that buprenorphine therapy should be continued perioperatively and that it is rarely appropriate to reduce the dose, irrespective of indication or formulation. 1
• Consider splitting the 6 mg daily dose into 2 mg every 8 hours (or 3 mg every 12 hours) to provide more consistent analgesic coverage throughout the day. 1, 2
• Abrupt discontinuation precipitates opioid withdrawal, markedly increases relapse risk, and leads to increased morbidity and mortality in patients with OUD. 2, 3

Multimodal Non-Opioid Analgesia (First-Line)

• Maximize non-opioid adjuncts as the cornerstone of treatment: 2
  • NSAIDs (ibuprofen 600-800 mg every 6-8 hours or ketorolac if appropriate) 2
  • Acetaminophen 1000 mg every 6-8 hours 2
  • Local anesthetic infiltration by the oral surgeon at the surgical site 2
  • Consider gabapentin (300-600 mg preoperatively and continued postoperatively) or pregabalin for neuropathic pain components 2
  • Ice packs and elevation for the first 48 hours

Breakthrough Opioid Analgesia

• Add full mu-opioid agonists (hydrocodone/acetaminophen or oxycodone) on top of continued buprenorphine for breakthrough pain. 1, 2
• Expect to prescribe 2-4 times the typical opioid dose due to buprenorphine's high receptor affinity creating competitive blockade at mu-opioid receptors. 2
• For complicated oral surgery with bone grafts, consider prescribing:
  • Hydrocodone/acetaminophen 10/325 mg every 4-6 hours as needed (rather than the typical 5/325 mg dose) 2
  • OR Oxycodone 10-15 mg every 4-6 hours as needed (rather than typical 5-10 mg) 1, 2
• Titrate upward if analgesia remains inadequate after optimizing adjunctive therapies. 1

Clinical Rationale

Why Continue Buprenorphine

The 2021 SPAQI consensus statement notes that while there is no consensus for doses >12 mg daily, low-dose formulations (<12 mg) can be continued perioperatively. 1 At 6 mg daily, this patient falls well below the threshold where dose reduction would even be considered. 1

Stopping buprenorphine does NOT improve pain control and causes significant harm: 2, 3, 4

• Interruption of buprenorphine may result in failure to return to baseline doses, continuing non-buprenorphine opioid use, or relapse of opioid use disorder. 4
• Discontinuation undermines harm-reduction strategies and reduces treatment retention for OUD, a condition with life-threatening consequences. 2

Why Full Agonists Work Despite Buprenorphine

While buprenorphine's high affinity for mu-receptors creates competitive blockade, full mu-agonists can still provide analgesia when dosed appropriately. 1, 2 The key is using higher-than-normal doses and not expecting typical dose-response relationships. 2

Practical Implementation Algorithm

1. Preoperatively:

   • Verify the patient's current 6 mg Suboxone dose and last administration time
   • Inform the oral surgeon and anesthesiologist about continued buprenorphine therapy 1
   • Prescribe gabapentin 300-600 mg to take 1-2 hours before surgery 2

2. Day of Surgery:

   • Patient takes morning Suboxone dose as scheduled 1, 2
   • Surgeon provides local anesthetic infiltration 2
   • Consider splitting future doses to every 8-12 hours starting postoperatively 1, 2

3. Postoperative Days 1-5:

   • Continue Suboxone 6 mg daily (or split to 2 mg TID or 3 mg BID) 1, 2
   • Standing doses: Ibuprofen 600-800 mg every 6-8 hours + Acetaminophen 1000 mg every 6-8 hours 2
   • Breakthrough pain: Hydrocodone/acetaminophen 10/325 mg every 4-6 hours PRN (expect to need higher doses) 1, 2
   • Ice packs and elevation

4. Days 6-14:

   • Taper opioid analgesics as pain improves
   • Continue non-opioid adjuncts
   • Return to baseline once-daily Suboxone dosing if split-dosing was used 2

Critical Pitfalls to Avoid

• Do NOT discontinue buprenorphine preoperatively – this is the single most harmful intervention and provides no analgesic benefit. 1, 2, 3, 4
• Do NOT underdose opioid analgesics – typical doses will be insufficient; expect 2-4 times normal requirements. 2
• Do NOT rely solely on opioids – multimodal analgesia is essential to minimize total opioid requirements. 2
• Do NOT fail to coordinate with the patient's buprenorphine prescriber – inform them of the surgery and analgesic plan to ensure continuity of OUD treatment. 2, 3
• Monitor respiratory status carefully if using high-dose opioids on top of buprenorphine, though the ceiling effect of buprenorphine provides some protection against respiratory depression. 1, 2

Care Coordination

• Contact the patient's buprenorphine prescriber before and after surgery to coordinate care and document any controlled substances prescribed. 1, 3
• Ensure the patient has a clear plan to transition off short-acting opioids and return to baseline buprenorphine maintenance therapy. 3, 4
• Schedule follow-up within 1-2 weeks to assess pain control, opioid tapering, and OUD treatment stability. 3