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Discontinuing Buprenorphine Prior to Surgery


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This question was submitted through pcssNOW.org:

I work with post operative surgical patients such as orthopedics. Recently I have come across several patients on Butrans and belbuca for chronic pain. I have been reviewing research and would like more understanding about these medications regarding post operative pain control. The problem I am seeing is prior to surgery the perioperative team and anesthesia will have the patient discontinue their belbuca or transderma buprenorphine. When they do this the patient seems to require more opioids like hydromorphone for pain control. I have also read through anesthesia guidelines that for the transdermal and belbuca that they should not be discontinued prior to surgery why is this? I would like more understanding so that I can educate myself so that I can better treat post operative patients with a history of chronic pain and pass this information to my surgeons and anesthesia department.

 

Dr. Adam Bisaga responds:

At present, the consensus is to continue perioperative buprenorphine, whether sublingual, transdermal or transmucosal whenever possible. Here are few of the recent papers summarizing existing evidence

https://pubmed.ncbi.nlm.nih.gov/31153631/

https://pubmed.ncbi.nlm.nih.gov/32520814/

https://pubmed.ncbi.nlm.nih.gov/30484167/

 

In addition to Dr. Bisaga's response above, here are some previous threads that may be of use:

 

Finally I would recommend being connected with one of our PCSS pain mentors for some one-on-one guidance on issues like these.  If you are interested please let me know!

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  • 4 weeks later...

Greetings Mr. Acton,

This question has been contemplated for as far back as I can remember over my 12 or so years of providing MAT in a unique sort of small rural community that happens to also have med school. Ive seen all kinds of requests come in from oral surgeons, orthopedics, and anesthesia providers where I used to get that request for 7 days off suboxone before they would perform anesthesia. My concern always had been the high risk, if not certainty, of relapse. I was blessed to have an recovered anesthesiologist on staff & we had many a discussion on tapers & how it would effect the patients overall being particularly those new to MAT & scared to death from some remarks they had heard from other practitioners with very little knowledge of either addiction or Suboxone. We started with keeping them on suboxone & adding a full agonist as needed with rather poor results across the board. We then changed course & had them stop the suboxone pre-op, which then of course the question of when to stop & when to resume their MAT. Now add to this the newer data indicating that ex- or recovering opioid addicts may in fact require higher doses of full agonist opioids to obtain the same level of analgesia. Try explaining this to other providers hesitant to prescribe any opioid at all due to a patients history of opioid use disorder. We saw our clients discharged in severe pain with nothing but an advisory to go take some ibuprofen for pain after major surgical procedures. My favorite to date was to stop on the way home and pick up some lavender oil to inhale if the pain became too unbearable. We routinely saw our patients have horrible relapses including many now trying heroin for the first time ever. We started making phone calls in response to these faxes coming in requesting the 7 day suboxone holds. As a group we decided we simply needed to take the time to discuss these concepts with the surgeons and anesthesiologists explaining that "they would have done that long ago if they could have for 1 day, let alone an entire week". We advised the providers our suggestion was to have our patients take their last partial dose of suboxone (2 to 4 mg) in the late afternoon the day before surgery.  Proceed with anesthesia with the knowledge their would be only a minimal amount of buprenorphine on the receptors. Then to either prescribe the patient the full opioid agonist dose they gave to their other standard patients and doubling the dosage for a  24 hour regimen, (with the further caveat that we would prescribe it if they were uncomfortable doing so). Then we had advised our patients to take the pain meds they needed to remain comfortable up until bedtime on the day of the surgery & resume their suboxone dosage the morning of day 2 post op. Our success with his method has been absolutely amazing with grateful patients that felt no guilt or fear they wouldn't be taken care of. The key has been educating our peers on the evidence, and letting them know we are more than happy to cover pain management for our OUD patients. When we write prescriptions we aways advise they use the same pharmacy to fill for the opioid &  we include a note about the plan w instructions to the pharmacist about the surgical procedure for which the full agonist opioid is needed & to resume the suboxone on day 2 post-op. Another benefit is we never get calls from pharmacies while patients sit there in pain & feel humiliated just out of surgery...

Someday, it will be amazing when our peers in other specialties just make the effort to call & ask us questions about addiction, rather than the standard contempt prior to investigation.

MichaelMD

 

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