What postoperative analgesic regimen should be used for a patient on 6 mg daily buprenorphine/naloxone (Suboxone) with high opioid tolerance undergoing oral surgery with bone grafts and mandibular bone smoothing who requests hydromorphone or morphine?

Postoperative Analgesic Regimen for Oral Surgery in a Patient on 6 mg Daily Buprenorphine/Naloxone

Continue the patient's 6 mg daily buprenorphine/naloxone unchanged throughout the perioperative period, split into 2 mg every 8 hours or 3 mg every 12 hours for more consistent analgesic coverage, and add hydromorphone or morphine on top at 2–4 times typical doses for breakthrough pain, combined with aggressive multimodal non-opioid analgesia. 1

Buprenorphine Management

• Never discontinue buprenorphine perioperatively—stopping it precipitates withdrawal, dramatically increases relapse risk to illicit opioids, and does not improve pain control. 1, 2, 3

• The 6 mg daily dose falls well below the 12 mg threshold where dose reduction would even be considered, so continue it unchanged. 1

• Split the 6 mg daily dose into either 2 mg every 8 hours or 3 mg every 12 hours to provide more consistent receptor occupancy and analgesic coverage throughout the postoperative period. 1

• The patient should take their scheduled morning buprenorphine dose on the day of surgery as usual. 1

• Inform the surgical and anesthesia teams that buprenorphine will be continued unchanged—this is critical for coordinated pain management. 1

Multimodal Non-Opioid Foundation

Aggressive multimodal analgesia must be the cornerstone of treatment because patients on buprenorphine require higher opioid doses due to competitive receptor blockade. 1

• Scheduled acetaminophen (1000 mg every 6–8 hours, maximum 4000 mg/day) should be started immediately postoperatively and continued throughout recovery. 1

• Scheduled NSAID (e.g., ibuprofen 600 mg every 6 hours or naproxen 500 mg twice daily) unless contraindicated by bleeding risk or renal impairment. 1

• Local anesthetic infiltration by the surgeon at the surgical site provides excellent adjunctive analgesia for oral surgery. 1

• Ice packs and elevation for the first 48 hours reduce swelling and pain. 1

• Consider gabapentin (300–600 mg three times daily) or pregabalin as an additional opioid-sparing adjunct. 1

Breakthrough Opioid Analgesia: Hydromorphone or Morphine

The patient's request for hydromorphone or morphine is clinically appropriate—both are full mu-opioid agonists that can be safely added on top of continued buprenorphine. 1, 4

Key Pharmacologic Principle

• Buprenorphine's high receptor affinity creates competitive blockade, requiring 2–4 times the typical opioid dose to achieve adequate analgesia. 1

• Full mu-agonists (hydromorphone, morphine, oxycodone) do not antagonize each other and can be used sequentially or in combination without waiting periods. 5, 4

• Combination of buprenorphine with full mu-agonists in the analgesic dose range results in additive or synergistic effects, not antagonism. 4

Specific Dosing Recommendations

For complex oral surgery with bone grafts and mandibular bone smoothing:

• Hydromorphone: 2–4 mg PO every 4–6 hours as needed (instead of the usual 1–2 mg), or 0.4–1 mg IV every 2–3 hours as needed (instead of the usual 0.2–0.5 mg). 1, 6

• Morphine: 10–20 mg PO every 4 hours as needed (instead of the usual 5–10 mg), or 2–4 mg IV every 2–3 hours as needed (instead of the usual 1–2 mg). 1

• Alternative (if hydromorphone/morphine unavailable): Oxycodone 10–15 mg PO every 4–6 hours as needed (instead of the usual 5–10 mg). 1

• If pain remains uncontrolled after optimizing non-opioid adjuncts, upward titration of the full agonist dose is advised—do not reduce or stop buprenorphine. 1

Intravenous Hydromorphone Administration (if used)

• Administer IV hydromorphone slowly over at least 2–3 minutes to minimize hypotension and respiratory depression risk. 6

• Start with 0.4–1 mg IV every 2–3 hours as needed, recognizing this is 2–4 times the typical starting dose due to buprenorphine blockade. 1, 6

Postoperative Timeline

Days 1–5

• Continue buprenorphine 2 mg every 8 hours (or 3 mg every 12 hours). 1

• Scheduled acetaminophen and NSAID dosing. 1

• Breakthrough hydromorphone or morphine at the doses above, as needed. 1

Days 6–14

• Taper short-acting opioid analgesics as pain improves while maintaining non-opioid adjuncts. 1

• Return to baseline once-daily buprenorphine schedule (6 mg daily) once split-dosing is no longer needed. 1

Safety Monitoring

• Monitor respiratory status, sedation level, and pain scores regularly, especially when high-dose opioids are administered on top of buprenorphine. 1

• Buprenorphine's ceiling effect on respiratory depression offers some protection, but vigilance is still required when combining with full agonists. 1, 2

• Avoid rapid IV administration of hydromorphone—give slowly over 2–3 minutes to prevent hypotension and respiratory depression. 6

Care Coordination

• Contact the patient's buprenorphine prescriber before and after surgery to coordinate medication management and document any controlled-substance prescriptions. 1

• Provide clear discharge instructions on how to safely self-administer opioids, wean analgesics, and dispose of unused medication. 5

• The discharge letter must explicitly state the recommended opioid dose and planned duration. 5

Common Pitfalls to Avoid

• Do not stop buprenorphine—this is the single most important principle; discontinuation precipitates withdrawal, increases relapse risk, and does not improve analgesia. 1, 2, 3, 7

• Do not underdose breakthrough opioids—expect to prescribe 2–4 times typical doses due to buprenorphine's competitive receptor blockade. 1

• Do not use mixed agonist-antagonists (pentazocine, nalbuphine, butorphanol) or switch to partial agonists—these may precipitate withdrawal or reduce analgesia. 6

• Do not delay breakthrough opioid administration based on misconceptions about drug interactions—full mu-agonists can be given immediately when needed without waiting periods. 5, 4