Treating Perioperative and Acute Pain in Patients on Buprenorphine: Narrative Literature Review and Practice Recommendat
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Division of Addiction Medicine, Johns Hopkins School of Medicine, Baltimore, MD, USA; 2Department of Family and Community Medicine, Penn State College of Medicine, Hershey, PA, USA; 3Department of Anesthesiology and Perioperative Medicine, Penn State Hershey Medical Center, Hershey, PA, USA; 4Divisions of General Internal Medicine and Addiction Medicine, Johns Hopkins School of Medicine, Baltimore, MD, USA; 5Pyramid Healthcare, Inc., Duncansville, PA, USA.
Opioid use disorder (OUD), a leading cause of morbidity and mortality in the USA, can be effectively treated with buprenorphine. However, the same pharmacologic properties (e.g., high affinity, partial agonism, long half-life) that make it ideal as a treatment for OUD often cause concern among clinicians that buprenorphine will prevent effective management of acute pain with full agonist opioid analgesics. Because of this concern, many patients are asked to stop buprenorphine preoperatively or at the onset of acute pain, placing them at high risk for both relapse and a difficult transition back to buprenorphine after acute pain has resolved. The purpose of this review is to summarize the existing literature for acute pain and perioperative management in patients treated with buprenorphine for OUD and to provide practical management recommendations for generalist practitioners based on evidence and clinical experience. In short, evidence suggests that sufficient analgesia can be achieved with maintenance of buprenorphine and use of both opioid and non-opioid analgesic options for breakthrough pain. We r e c o m m e n d t h a t c l i n i c i a n s ( 1 ) c o n t i n u e buprenorphine in the perioperative or acute pain period for patients with OUD; (2) use a multi-modal analgesic approach; (3) pay attention to care coordination and discharge planning when making an analgesic plan for patients with OUD treated with buprenorphine; and (4) use an individualized approach founded upon shared decision-making. Clinical examples involving mild and severe pain are discussed to highlight important management principles. KEY WORDS: buprenorphine; perioperative; acute pain; opioid use disorder J Gen Intern Med DOI: 10.1007/s11606-020-06115-3 © Society of General Internal Medicine 2020
Jessica Ratner contributed equally to the work. Received January 28, 2020 Accepted August 5, 2020
use disorder (OUD) is a chronic disease affecting O pioid 2.1 million Americans, and opioid-related overdose is 1
one of the leading causes of preventable mortality for Americans.2 Many patients with OUD also suffer from pain. Buprenorphine, a semi-synthetic opioid, was first developed in the 1970s as an analgesic with parenteral and sublingual formulations.3 It was subsequently found to be an effective treatment for OUD, decreasing opioid withdrawal and craving, illicit opioid use, and mortality.4–7 The passage of the Drug Addiction Treatment Act (DATA) of 2000 allowed for buprenorphine to be prescribed in outpatient settings for treatment of OUD.3 There are now several formulations of buprenorphi
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