Last updated March 15, 2022

Buprenorphine Management in the Perioperative Period

Preoperative planning

Buprenorphine should not be routinely discontinued as adequate analgesia can be achieved (grade B, moderate level of certainty). 


Discontinuing buprenorphine can increase the risk of OUD recurrence or harm (grade B, moderate level of evidence). 


Current evidence suggests variation in recommendations with regard to tapering patients on high dose (>16 mg) of buprenorphine and in situations in which high levels of postoperative pain are anticipated; however, receptor availability studies and case reports suggest adequate analgesia can still be achieved even at high doses of buprenorphine. Thus, the working group recommends that, in addition to not routinely discontinuing buprenorphine prior to surgery, one should avoid tapering it perioperatively as well (grade B, moderate level of certainty).

Postoperative pain

Most available literature recommends the use of multimodal analgesia in the perioperative period in patients receiving buprenorphine for MOUD. Thus, the working group recommends that multimodal analgesia, including adjunctive medications and regional anesthesia techniques, should be used whenever possible (grade B, moderate level of certainty).


Additional evidence from opioid receptor binding studies and other literature review suggests that opioids can be administered in conjunction with buprenorphine to achieve adequate analgesia. Thus, it is the working group’s recommendation to consider administration of full mu agonists (with high affinity for the mu receptor) (grade B, moderate level of certainty) or increased and/or divided doses of buprenorphine (grade C, low level of certainty) with close monitoring for uncontrolled postoperative pain if multimodal analgesia proves inadequate.
 

Discharge planning

Most studies on postoperative opioid use suggest providing a plan to taper the patient off postoperative opioids once the acute pain resolves. A taper plan can assist in minimizing withdrawal, decreasing postsurgical opioid use, and maximizing successful discontinuation of acute opioids once pain has resolved. Appropriate surgical prescribing and follow-up may ensure patients have tapered off postoperative opioids and acute pain management has been addressed. Similarly, if a full mu agonist is initiated or if buprenorphine is increased during the perioperative period, the working group recommends a postdischarge plan to taper off the full mu agonist or return to the preoperative maintenance dose of buprenorphine (grade A, moderate level of certainty). 


Additionally, length of recovery should be considered when prescribing full mu agonists on discharge. While providing full mu agonists with a taper plan may be reasonable for patients in stable recovery, caution is advised in those with active/recent illicit opioid use. Providing multiple daily prescriptions with ‘do not fill’ dates may be one technique to help mitigate the risk on this circumstance.


In addition, evidence from existing literature supports the working group’s recommendation to engage in ongoing collaboration with the patient’s outpatient buprenorphine prescriber (grade A, moderate level of certainty).


Patients with suspected OUD can be approached and educated about the benefits of initiating buprenorphine postoperatively. Current literature, largely from the field of EM, has demonstrated that initiation of buprenorphine for patients with OUD results in decreased use of illicit substances and greater retention in OUD treatment programs. Safe initiation of buprenorphine with linkage to a community provider was described in several available EM studies, as well as by an anesthesia-led team in a case series. Thus, based on both review of this literature and expert opinion, it is the working group’s recommendation that, when possible and clinically indicated, anesthesiologists/pain physicians can consider recommending or starting buprenorphine for postoperative analgesia in patients with suspected OUD, using available social work or ancillary services to help facilitate linkage to outpatient buprenorphine prescribers when possible (grade of evidence B, moderate level of certainty).


One additional recommendation, based on physician expertize/comfort, is that buprenorphine treatment can still be considered in circumstances in which follow-up/insurance coverage has not been fully established (grade of evidence C, low level of certainty).

Strategies for in-hospital management of patients with opioid use disorder (OUD)

Screening
  • Most patients will disclose their substance use history when asked.
  • Urine toxicology is generally not required but may be useful, particularly in identifying patients who have recently taken methadone, which may make initiation of buprenorphine more difficult.
  • Some clinics may require a positive urine toxicology for opioids prior to medication treatment of opioid use disorder (MOUD) treatment, which may be important when linking to community care.


Medication administration
  • See committee recommended algorithm. Figure 2 (inpatient buprenorphine initiation).
  • The Clinical Opioid Withdrawal Scale may be a useful tool to help physicians and nurses who are new to diagnosing opioid withdrawal. Use of subjective signs and objective signs of withdrawal is also valid.
  • May include naloxone for respiratory rate <8 breaths per minute.


Discharge planning
  • If able, provide buprenorphine prescription for OUD as bridge to community-linked treatment. Requires x-waivered physician.
  • If an x-waivered provider is not available, ensure immediate linkage to community clinic providing MOUD care.
  • Provide naloxone prescription or information at discharge.
  • Provide information for follow-up to community-linked clinic.

Recommendation Grading

Overview

Title

Buprenorphine Management in the Perioperative Period

Authoring Organization

Publication Month/Year

August 19, 2021

Document Type

Consensus

Country of Publication

US

Inclusion Criteria

Male, Female, Adult, Older adult

Health Care Settings

Ambulatory, Hospital, Outpatient

Intended Users

Nurse, nurse practitioner, physician, physician assistant

Scope

Assessment and screening, Management

Diseases/Conditions (MeSH)

D009293 - Opioid-Related Disorders, D019990 - Perioperative Care

Keywords

buprenorphine, perioperative, perioperative care, OUD, Opioid Use Disorder

Source Citation

Kohan L, Potru S, Barreveld AM, Sprintz M, Lane O, Aryal A, Emerick T, Dopp A, Chhay S, Viscusi E. Buprenorphine management in the perioperative period: educational review and recommendations from a multisociety expert panel. Reg Anesth Pain Med. 2021 Oct;46(10):840-859. doi: 10.1136/rapm-2021-103007. Epub 2021 Aug 12. PMID: 34385292.