Table 7

Summary of case reports/series, reviews, and published guidelines on management of buprenorphine in the perioperative period

StudyStudy typeFindings and perioperative recommendations from literature
Book SW et al92Case reportPatient successfully maintained on 24/6 mg buprenorphine/naloxone up to the day of surgery. Additional sublingual doses of buprenorphine aided in postoperative pain control.
Marcucci C et al148Case reportA man aged 47 years underwent total hip arthroplasty, patient on one tab sublingual buprenorphine every 4 hours (unknown dose of tab). Buprenorphine discontinued day of surgery. Poor postoperative pain control.
Brummett CM et al 149Case reportA man aged 41 years underwent postposterior lumbar spinal fusion. Patient on 16 mg maintenance dose that was discontinued day of surgery. Postoperative pain poorly controlled.
Recommendation: discontinue buprenorphine.
Rodgman C et al150Case reportA female patient aged 29 years underwent heart transplant. Patient on 24 mg buprenorphine maintenance dose. Buprenorphine discontinued 12 hours preoperatively. Postoperative pain control poor.
Recommendation: continue buprenorphine.
McCormick et al151Case reportA man aged 50 years with McArdle’s disease on 24 mg buprenorphine/naloxone with exertional rhabdomyolysis requiring fasciotomies. Buprenorphine discontinued 12 hours prior to surgery. Postoperative pain poorly controlled.
Patient with high intravenous hydromorphone requirements.
Weaning and discontinuation recommendations provided.
Chern SY et al93Case reportCase report of a woman aged 37 years on buprenorphine with Chiari I malformation, hepatitis C, hypothyroidism. Patient had multiple urogynecological procedures, reported poor pain control with continuing buprenorphine perioperatively as well as poor pain control with stopping buprenorphine and bridging with oral hydromorphone for 5 days preoperatively.
Recommendation: discontinue buprenorphine.
Israel JS et al152Case reportA woman aged 37 years underwent bilateral mastectomy; home buprenorphine dose unknown. Buprenorphine discontinued prior to surgery; postoperative pain poorly controlled.
Huang A et al94Case reportA woman aged 47 years for Clagett window procedure for pulmonary aspergillosis. Suboxone 16 mg two times per day preoperative, and had poor postoperative pain control that led to postoperative taper of Suboxone with improvement in pain. Managed on oral hydromorphone at time of discharge.
Recommendation: discontinue buprenorphine.
Khelemsky Y et al153Case reportA woman aged 44 years with cervical spine surgeries 5 days apart. Patient had reduced total intravenous anesthesia requirements for the latter surgery when Suboxone (8/2 mg, three times a day) was stopped after first surgery.
Weaning of Suboxone preoperatively is suggested.
Silva MJ et al77Case reportA man aged 53 years had one total knee arthroplasty on each knee approximately 2 years apart. Patient had better postoperative pain control while on buprenorphine after first surgery (he was not on buprenorphine prior to second surgery).
Continuation of buprenorphine perioperatively is discussed.
Jones et al154Case series
n=2		Buprenorphine* and methadone can be continued throughout the peripartum period without risk. Adequate pain control can be achieved while patient is on maintenance dose with use of short-acting full mu agonists, acetaminophen and NSAIDs.
Kornfeld H et al76Case series
n=5, 7 cases (2 patients had 2 procedures)		Buprenorphine dose (ranging from 2 to 24 mg preoperatively) maintained, decreased, or discontinued prior to surgery.
Pain well controlled in all patients regardless of discontinuing, maintaining, or increasing perioperatively/postoperatively.
Recommendation: maintain stable buprenorphine dosing for patients who require major surgery.
Mercadante S et al80Prospective cohort study
n=29		Patients with cancer. Transdermal buprenorphine did not interfere with efficacy of intravenous morphine for breakthrough analgesia in most patients.
Hansen LE et al103Prospective cohort studyContinue buprenorphine/naloxone or methadone for total knee and total hip arthroplasty. No significant difference between groups.
Recommendation: buprenorphine can be continued.
Höflich A et al155Retrospective cohort studyMethadone and buprenorphine can be continued in the peripartum period with adequate postpartum pain control.
Limitation: methadone and buprenorphine patients combined into one group.
Macintyre PE et al75Retrospective cohort study
n=51		Pain relief and opioid requirements in first 24 hours compared between methadone and buprenorphine.
No difference between the two groups. No difference in pain control with continuing versus stopping buprenorphine.
Continuation of buprenorphine recommended: mean dose 13.6 mg (±6.6 mg).
Vilkins AL et al78Retrospective cohort study
n=273		Postcesarean section opioid requirements compared for patients on methadone or buprenorphine. No significant differences in oral morphine equivalents in methadone or buprenorphine groups.
Conclusion: buprenorphine will not interfere more than methadone for postcesarean section pain management.
Goel A et al83Systematic reviewNo evidence against continuing buprenorphine in the perioperative period, especially when dose is <16 mg. There should be strong rationale for stopping buprenorphine prior to surgery, especially in patients with recent history of OUD.
Warner NS et al84Systematic reviewNon-emergent: low pain expected: continue home buprenorphine dose; moderate-to-high pain expected: continue buprenorphine if taking ≤8 mg, moderate-to-high dose-consult buprenorphine provider, may continue current home dose or decease to 8–12 mg prior to surgery
Emergent: low dose (≤8 mg) continue current dose; high dose: continue current dose, use multimodal techniques, if pain inadequately controlled consult buprenorphine provider and possibly decrease dose to 8–12 mg.
Mehta D et al156Systematic review18 publications; no clear benefit to bridging or stopping buprenorphine; failure to restart might pose concerns for OUD recurrence.
Recommendation: continue buprenorphine for OUD perioperatively; use interdisciplinary approach with multimodal analgesia.
Alford DP et al157ReviewMultiple perioperative recommendations given including continuing buprenorphine and adding short-acting opioids, dividing the daily dose of buprenorphine to every 6–8 hours. Discontinue and treat with short-acting opioids or convert to methadone.
Childers JW et al158ReviewMild/moderate pain: consider treating with buprenorphine alone or adding short acting full mu agonists as needed.
Hold buprenorphine and start short-acting full mu agonists if expecting moderate/severe pain. Replace buprenorphine with methadone if prolonged pain is expected. Adjuvant analgesics and regional techniques should be employed.
Bryson EO et al159ReviewWhen possible, evaluate patient to see if buprenorphine can be discontinued 72 hours prior to surgery.
Sen S et al160ReviewDiscontinue buprenorphine 72 hours before surgery. Replace buprenorphine with methadone.
Anticipate additional opioid doses for pain control.
Anderson TA et al73ReviewPatients can be stratified into urgent versus elective surgery; consider stopping buprenorphine for 24–72 hours if elective surgery with moderate-to-severe postoperative pain.
Consider adjuvants: NSAIDs, membrane stabilizers, acetaminophen, local anesthetics, and regional anesthesia.
Jonan AB et al161ReviewMild postoperative pain: continue buprenorphine without taper.
Moderate pain: discontinue buprenorphine 3–5 days before procedure, consider high-dose intravenous full-mu agonist patient controlled analgesia. Severe pain: discontinue buprenorphine 3–5 days before procedure; consider full mu agonist to prevent withdrawal.
Use non-opioids, regional anesthesia, and local anesthetics when possible.
Ward EN et al65ReviewContinue buprenorphine for mild-severe pain. Recommendation: multimodal analgesia.
Harrison TK et al162ReviewContinue buprenorphine at home dose throughout perioperative period. If needed postoperatively, consider increasing buprenorphine to control pain.
Quaye AN et al88ReviewMild pain: continue home dose of buprenorphine. Moderate-to-severe pain: reduce dose to 16 mg up to the day before surgery and 8 mg on day of surgery and maintain 8 mg daily. When surgical pain subsides, taper off full mu agonists and resume home buprenorphine dose.
Lembke A et al63EditorialContinue buprenorphine in the perioperative period for patients taking ≤12 mg; for those taking higher doses, taper to 12 mg, 2–3 days prior to surgery. Anticipate higher-than-usual doses of short-acting full mu agonists for 2–4 days postoperative.
Berry P et al (Vermont Guidelines) 163GuidelinesDecrease buprenorphine to 8 mg sublingual on day of surgery; buprenorphine above 10 mg will block opioid analgesics. Use short-acting full mu agonists for postoperative pain; may need to use for longer period of time than anticipated.
ASAM National Practice Guideline81GuidelinesDiscontinuation of methadone or buprenorphine is not required. Higher potency full mu agonists can be used perioperatively in addition to the patients’ regular dose.
Goel et al 91Clinical practice advisory/expert opinionContinue buprenorphine at same dose perioperatively. If multimodal analgesia ineffective, consider decreasing buprenorphine dose.
TIP 4074Treatment improvement protocolDiscontinue buprenorphine and use short-acting opioids (higher doses may be necessary).

  • *Patient was on 18 mg buprenorphine.

  • NSAID, non-steroidal anti-inflammatory drug; OUD, opioid use disorder.