Perioperative pain management and outcomes in patients who discontinued or continued pre-existing buprenorphine therapy

Aamer Attaar, PharmD, BCPS; Molly Curran, PharmD, BCPS, BCCCP; Lyndsi Meyenburg, PharmD, BCPS; Richard Bottner, DHA, PA-C; Clarissa Johnston, MD; Kirsten Roberts Mason, PharmD, BCPS

doi:10.5055/jom.2021.0640

Authors

Aamer Attaar, PharmD, BCPS https://orcid.org/0000-0002-7542-7135
Molly Curran, PharmD, BCPS, BCCCP
Lyndsi Meyenburg, PharmD, BCPS
Richard Bottner, DHA, PA-C
Clarissa Johnston, MD
Kirsten Roberts Mason, PharmD, BCPS https://orcid.org/0000-0002-7187-9134

DOI:

https://doi.org/10.5055/jom.2021.0640

Keywords:

buprenorphine, pain, surgery

Abstract

Objective: This study compared opioid utilization and clinical outcomes in surgical patients receiving maintenance buprenorphine therapy who discontinued versus those who continued buprenorphine treatment perioperatively. Lack of high-quality evidence, conflicting results in previous studies, and the possible need for reinduction after discontinuing therapy present clinicians with the complicated dilemma of choosing the best strategy to control post-operative pain in patients receiving buprenorphine.

Design: A multicenter, retrospective cohort study.

Participants: Hospitalized patients between January 1, 2017 and December 12, 2019 who underwent any type of surgery, had a documentation of an outpatient buprenorphine prescription or inpatient order, and received buprenorphine for 5 or more days prior to the procedure were included.

Main outcome measure(s): The primary objective was to compare mean 24-hour morphine milligram equivalent (MME) utilization post-operatively between patients who discontinued buprenorphine preoperatively versus those who continued therapy throughout the perioperative period.

Results: Fifty-one patients met the inclusion criteria for this study. Of these, 42 patients were continued on buprenorphine through surgery, while nine patients had a documentation of discontinuation preoperatively. The 24-hour post-operative MME utilization (interquartile range) was 58.8 (18-100.8) in patients who continued therapy through surgery versus 152.6 (114.5-236) in patients who discontinued therapy preoperatively (p = 0.005). There were no significant differences in post-operative pain scores or length of stay between groups.

Conclusion: Post-operative opioid use was significantly lower in patients who continued buprenorphine compared with those who discontinued buprenorphine preoperatively.

Author Biographies

Aamer Attaar, PharmD, BCPS

Dell Seton Medical Center at The University of Texas, Austin, Texas

Molly Curran, PharmD, BCPS, BCCCP

Ascension Seton Medical Center Austin, Austin, Texas

Lyndsi Meyenburg, PharmD, BCPS

Ascension Seton Northwest, Austin, Texas

Richard Bottner, DHA, PA-C

Dell Medical School at The University of Texas at Austin, Austin, Texas

Clarissa Johnston, MD

Dell Medical School at The University of Texas at Austin, Austin, Texas

Kirsten Roberts Mason, PharmD, BCPS

Ascension Seton Medical Center Austin, Austin, Texas

References

Olfson M, Zhang V, Schoenbaum M, et al.: Trends in buprenorphine treatment in the United States, 2009-2018. JAMA. 2020; 323(3): 276-277.

Velander JR: Suboxone: Rationale, science, misconceptions. Ochsner J. 2018; 18(1): 23-29.

Anderson TA, Quave ANA, Ward EN, et al.: To stop or not, that is the question: Acute pain management for the patient on chronic buprenorphine. Anesthesiology. 2017; 126(6): 1180-1186.

Quaye AN, Zhang Y: Perioperative management of buprenorphine: Solving the conundrum. Pain Med. 2019; 20(7): 1395-1408.

Substance Abuse and Mental Health Services Administration: Medications for Opioid Use Disorder. Treatment Improvement Protocol (TIP) Series 63. Publication No. PEP20-02-01-006. Rockville, MD: Substance Abuse and Mental Health Services Administration, 2020.

Sordo L, Barrio G, Bravo MJ, et al.: Mortality risk during and after opioid substitution treatment: Systematic review and meta-analysis of cohort studies. BMJ. 2017; 357: J1550.

Huang A, Katznelson R, de Perrot M, et al.: Perioperative management of a patient undergoing clagett window closure stabilized on suboxone(R) for chronic pain: A case report. Can J Anesth/J Can Anesth. 2014; 61(9): 826-831.

Gilmore T, Saccheti A, Cortese T: Buprenorphine/naloxone inhibition of remifentanil procedural sedation. Am J Emerg Med. 2012; 30(8): 1655.e3-1655.e4.

McCormick Z, Chu SK, Chang-Chien GC, et al.: Acute pain control challenges with buprenorphine/naloxone therapy in a patient with compartment syndrome secondary to McArdle's disease: A case report and review. Pain Med. 2013; 14(8): 1187-1191.

Israel JS, Poore SO: The clinical conundrum of peri-operative pain management in patients with opioid dependence: Lessons from two cases. Plast Reconstr Surg. 2013; 131(4): 657e-658e.

Chern SYS, Isserman R, Chen L, et al.: Perioperative pain management for patients on chronic buprenorphine: A case report. J Anesth Clin Res. 2013; 3(250): 1000250.

Greenwald M, Johanson CE, Bueller J, et al.: Buprenorphine duration of action: Mu-opioid receptor availability and pharmacokinetic and behavioral indices. Biol Psychiatry. 2007; 61(1): 101-110.

Greenwald MK, Comer SD, Fiellin DA: Buprenorphine maintenance and mu-opioid receptor availability in the treatment of opioid use disorder: Implications for clinical use and policy. Drug Alcohol Depend. 2014; 144: 1-11.

Comer SD, Walker EA, Collins ED: Buprenorphine/naloxone reduces the reinforcing and subjective effects of heroin in heroin-dependent volunteers. Psychopharmacology. 2005; 181(4): 664-675.

UCSF guideline for the perioperative management of buprenorphine. Updated January 17, 2018. Available at https://anesthesia.ucsf.edu/sites/anesthesia.ucsf.edu/files/person/photo/perioperative_buprenorphine_guideline_0.pdf. Accessed September 12, 2019.

Carr DB, Jacox AK, Chapman CR, et al.: Acute pain management: Operative or medical procedures and trauma. Clinical Practice Guideline No. 1. AHCPR Pub no. 92-0032. Rockville, MD: US Public Health Service, Agency for Health Care Policy and Research, February 1992.

Hansen LE, Stone GL, Matson CA, et al.: Total joint arthroplasty in patients taking methadone or buprenorphine/naloxone preoperatively for prior heroin addiction: A prospective matched cohort study. J Arthroplasty. 2016; 31(8): 1698-1701.

Macintyre PE, Russell RA, Usher KA, et al.: Pain relief and opioid requirements in the first 24 hours after surgery in patients taking buprenorphine and methadone opioid substitution therapy. Anaesth Intensive Care. 2013; 41(2): 222-230.

Martin YN, Deljou A, Weingarten TN, et al.: Perioperative opioid requirements of patients receiving sublingual buprenorphinenaloxone: A case series. BMC Anesthesiol. 2019; 19(68): 1-7.

Jones HE, Kaltenbach K, Heil SH, et al.: Neonatal abstinence syndrome after methadone or buprenorphine exposure. N Engl J Med. 2010; 363(24): 2320-2331.

Jones HE, O'Grady K, Dahne J, et al.: Management of acute postpartum pain in patients maintained on methadone or buprenorphine during pregnancy. Am J Drug Alcohol Abuse. 2009; 35(3): 151-156.

Jones HE, Johnson RE, Milio L: Post-cesarean pain management of patients maintained on methadone or buprenorphine. Am J Addict. 2006; 15(3): 258-259.

Meyer M, Paranya G, Keefer Norris A, et al.: Intrapartum and postpartum analgesia for women maintained on buprenorphine during pregnancy. Eur J Pain. 2010; 14(9): 939-943.