Should a buprenorphine transdermal patch be removed prior to anesthesia?

Perioperative Management of Buprenorphine Transdermal Patches

The decision to remove a buprenorphine transdermal patch before anesthesia should be individualized based on the patient's daily dose, indication for use (opioid use disorder vs. chronic pain), expected postoperative pain severity, and risk of relapse—but current expert consensus increasingly favors continuation in most cases rather than routine discontinuation. 1

Key Decision Framework

The 2021 Society for Perioperative Assessment and Quality Improvement (SPAQI) consensus provides the most recent guideline-level recommendation: "Individualize to patient and clinical circumstances" for buprenorphine patches (Butrans), with the decision reflecting the prescribed daily dose, indication for treatment, risk of relapse, and expected level of postsurgical pain. 1

Critical Factors to Consider:

1. Daily Dose and Formulation

• Patients on ≤12 mg sublingual equivalent (or low-dose transdermal patches) can typically continue perioperatively 1
• Higher doses may require dose reduction 2-3 days preoperatively rather than complete discontinuation 1

2. Indication for Buprenorphine

• Opioid Use Disorder (OUD): Continuation is strongly preferred to prevent relapse, which poses significant morbidity and mortality risks 1
• Chronic Pain: More flexibility exists, though continuation still often preferred 1

3. Expected Postoperative Pain

• Low-to-moderate pain procedures: Continue buprenorphine without taper 1
• High pain procedures: Historical recommendations suggested discontinuation 3-5 days preoperatively, but more recent consensus (2019) challenges this approach due to relapse concerns 1

Evolution of Recommendations

Important caveat: The evidence shows a clear shift in expert opinion. Older advisories (2012-2017) routinely recommended discontinuation 72 hours before surgery for moderate-to-severe pain procedures. 1 However, the 2019 PAIN Network consensus and 2019 Lembke guidelines represent a paradigm shift toward continuation, recognizing that relapse risk in OUD patients often outweighs analgesic management challenges. 1

Practical Management Strategy

If Continuing Buprenorphine (Preferred Approach):

• Leave transdermal patch in place 1
• Implement aggressive multimodal analgesia (NSAIDs, acetaminophen, ketamine, gabapentinoids, regional techniques) 1
• Expect higher-than-normal doses of full mu-agonist opioids may be needed for breakthrough pain (2-4 days post-surgery) 1
• Consider dividing maintenance dose and administering every 6-8 hours if using sublingual formulation 1

If Discontinuing (Less Preferred):

• Only consider for patients without OUD and with very high expected postoperative pain 1
• Discontinue 72 hours before surgery 1
• Consider replacing with methadone rather than abrupt cessation to prevent withdrawal 1
• Establish clear plan for reinitiation with buprenorphine provider 1

Critical Safety Considerations

Drug Interactions: Concomitant use of buprenorphine with QT-prolonging agents is contraindicated. 1 Multiple other interactions exist including risk of serotonin syndrome, paralytic ileus, and precipitation of withdrawal symptoms. 1

Common Pitfall: The belief that buprenorphine's partial agonist properties make it a "partial analgesic" is erroneous—it has full analgesic efficacy with a ceiling effect only for respiratory depression, not analgesia. 2

Anesthesia Awareness: If a patch is continued, the anesthesiologist must be informed of its presence, dose, timing of application, and indication for use to appropriately plan intraoperative and postoperative analgesia. 1

Evidence Quality Note

The 2019 British Journal of Anaesthesia PAIN Network guideline acknowledges that existing recommendations are built primarily on expert opinion and case reports rather than high-quality randomized trials. 1 The only randomized trial combined buprenorphine and methadone patients, limiting applicability. 1 Despite this limitation, the consensus strongly emphasizes that relapse prevention in OUD patients should take priority over theoretical concerns about postoperative pain management, as relapse carries substantial mortality risk. 1