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Difficulty: HardPharmacologic Interventions

A 38-year-old man is evaluated in the preoperative clinic prior to a scheduled open reduction and internal fixation of a severely displaced tibial plateau fracture. The procedure is planned for 3 days from today. His medical history is notable for severe opioid use disorder, which has been in sustained remission for 4 years. He is maintained on a stable daily dose of sublingual buprenorphine-naloxone (16 mg / 4 mg). He has no other chronic medical conditions and takes no other medications. Vital signs are within normal limits. The patient expresses significant anxiety regarding postoperative pain control and fears that his current medication will interfere with his pain management. Which of the following is the most appropriate pharmacologic strategy regarding his opioid use disorder therapy in the perioperative period?

  1. Continue the current buprenorphine-naloxone dose through the day of surgery and utilize multimodal analgesiaAnswer
  2. B
    Discontinue the medication 72 hours prior to surgery and bridge with an oral full mu-opioid agonist
  3. C
    Transition to sublingual buprenorphine monotherapy to prevent postoperative naloxone-induced hyperalgesia
  4. D
    Decrease the medication dose by half on the morning of surgery to free mu-receptors for full opioid agonists
  5. E
    Withhold the medication entirely on the day of surgery and resume once parenteral opioid requirements cease

Answer

Continue the current buprenorphine-naloxone dose through the day of surgery and utilize multimodal analgesia
Continuing the current buprenorphine-naloxone dose is the standard of care for patients undergoing surgery. Buprenorphine is a partial mu-opioid receptor agonist with high receptor affinity. Historically, it was routinely discontinued 72 hours prior to surgery due to theoretical concerns that it would block the analgesic effects of full opioid agonists needed for postoperative pain. However, current evidence-based consensus guidelines strongly recommend continuing buprenorphine perioperatively. Discontinuing the medication introduces significant risks, including acute opioid withdrawal, hyperalgesia, loss of tolerance, and a high risk of postoperative relapse or fatal overdose. Acute pain can be successfully managed while the patient remains on their baseline buprenorphine dose by utilizing a robust multimodal analgesic approach (e.g., regional anesthesia, NSAIDs, acetaminophen, ketamine) and utilizing higher doses of short-acting, high-affinity full mu-opioid agonists (e.g., fentanyl, hydromorphone) to outcompete the partial agonist blockade when necessary.

Step-by-Step Solution

1
Identify the clinical scenario
A patient with stable opioid use disorder on maintenance buprenorphine-naloxone is undergoing major elective surgery expected to cause severe acute pain.
Establishing the baseline therapy and the anticipated physiologic stress is necessary to formulate a perioperative plan.
2
Analyze the pharmacodynamics of the patient's current therapy
Buprenorphine is a partial mu-opioid agonist with very high receptor affinity and slow dissociation, while naloxone has poor sublingual bioavailability.
Understanding these properties helps explain why historically buprenorphine was stopped, but also why stopping it is physiologically dangerous.
3
Apply current consensus guidelines for perioperative buprenorphine management
Current guidelines strongly recommend continuing buprenorphine at the baseline dose to prevent withdrawal and relapse.
The risks of stopping the medication (relapse, overdose upon resumption, severe withdrawal) far outweigh the theoretical difficulty in managing pain.
4
Determine the optimal postoperative pain strategy
Pain should be managed using a multimodal approach (regional blocks, NSAIDs, acetaminophen) alongside short-acting, high-affinity full mu-opioid agonists to overcome the buprenorphine blockade if needed.
This provides effective analgesia without compromising the patient's addiction recovery.

Key Concept

Patients maintained on buprenorphine for opioid use disorder should continue their baseline dose perioperatively to prevent withdrawal and relapse, with acute pain managed via multimodal analgesia and high-affinity full opioid agonists.
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Topics

Pharmacologic Interventions

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