Anesthetic Management of Patients Who is on Buprenorphine-Naloxone

Last week, I had a patient who is on suboxone.  As we know, patients who are on maintenance therapy of suboxone can pose a challenge for postop pain control as they often have severe postoperative pain due to  limited efficacy in the presence of buprenorphine. Hence, I figure it would be a good case for us to look up literature and see how to best manage patients perioperatively when patients are on suboxone maintenance therapy at home.

First of all, what is suboxone? Suboxone, aka buprenorphine-naloxone is an opioid agonist-antagonist combination used in the treatment of addiction-prone individuals.

Buprenorphine is a partial agonist, therefore it has a ceiling effect at higher doses and the risk of overdose is unlikely. It can also be used for chronic pain patients who are opioid dependent. As image shown on the right, naloxone is a full opioid antagonist that competes with other opioids. The addition of naloxone reduces the likelihood of people who are misusing it with injection. suboxone

As aforementioned, Buprenorphine has a long half-life of 24–60 hours,  which allows for every second day dosing if needed. Buprenorphine at a lower dose has the usual opioid effect. However, due to its partial agonist property,  high does do not result in higher analgesia effects after reaching a threshold. 

There are 4 recommendations based on the literature for preoperative buprenorphine contained medication management: 

  • continue buprenorphine and add additional postoperative buprenorphine if not reaching the ceiling effect (suboxone<8mg/day, Zubsolv<5.7mg, Bunavail<4.2mg/day)
  • continue baseline buprenorphine and add traditional opioids with high μ receptor affinity such as fentanyl or dilaudid.
  • reduce the baseline buprenorphine preoperatively if at a high dose (suboxone>8mg/day, Zubsolv>5.7mg, Bunavail>4.2mg/dayand then bridge with opioids with high μ receptor and/or multimodal pain management such as gabapentin, tramadol etc.  
  • discontinue buprenorphine 3-7 days prior to surgery and start a traditional opioid preoperatively. This may not be a viable approach as buprenorphine has a long half life and for emergent cases, patients may not be able to stop the medication early enough. In addition, patients may fear a relapse of their addition if abstaining from buprenorphine. 

Our facility recommends as shown below. My patient had a urology case for a stent placement. It is a minimal pain procedure. He continued his maintenance dose of 5mg suboxone and didn’t require any pain medication except toradol. For patients who are on higher dose, reducing suboxone to 8mg/day before the surgery produces better postop pain management compared to none-waning patients. ICU stay may be needed to have a better pain management with ketamine/lidocaine or precedex infusion.

Overall, keeping maintenance dose of suboxone is needed to prevent withdrawal. Depending on the surgical procedure, multimodal approach of pain management is preferrable.

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