Elsevier

Mayo Clinic Proceedings

Volume 95, Issue 6, June 2020, Pages 1253-1267
Mayo Clinic Proceedings

Review
A Practical Approach for the Management of the Mixed Opioid Agonist-Antagonist Buprenorphine During Acute Pain and Surgery

https://doi.org/10.1016/j.mayocp.2019.10.007Get rights and content

Abstract

The use of buprenorphine, a mixed opioid agonist-antagonist, for the management of chronic pain and/or opioid use disorder is increasing. As such, medical providers will more frequently encounter patients on this therapy. In this paper, we synthesize existing knowledge (derived through keyword searches using MEDLINE databases) in a novel conceptual framework for patients on buprenorphine presenting with acute pain or for those requiring surgical or invasive procedures. This framework is based on three unique domains: the patient, the features of the acute pain insult, and the environment. We discuss important considerations regarding the unique aspects of buprenorphine formulations and dosing, and we describe the importance of multidisciplinary planning and multimodal analgesic strategies. We also highlight important differences in management strategies based upon the presence or absence of opioid use disorder. All medical providers must be prepared to guide the patient on buprenorphine safely through the acute care episode, which includes adequate treatment of acute pain and avoidance of iatrogenic harm, including both short-term complications (eg, respiratory depression) and long-term complications (eg, relapse to opioid use).

Section snippets

Methods

Similar to previously published search strategies,13,14 databases of MEDLINE using the PubMed and Ovid platforms were searched using the key words buprenorphine, acute pain, surgery, preoperative, postoperative, perioperative, and discontinuation with no date restrictions. Key words pertaining to specific topics (eg, OUD, acute postoperative pain management, buprenorphine pharmacology, and opioid tapering) were cross-referenced with the initial search terms using the identified databases.

Conclusion

Buprenorphine use is increasingly common, and medical providers must be adequately prepared to manage these patients in both elective and emergent situations. The three domains to consider when confronted with the patient on buprenorphine who presents for surgery or acute pain include the patient, the features of the acute pain insult, and the environment. In general, patients undergoing procedures with low anticipated opioid requirements may continue buprenorphine therapy. Similarly, those

Acknowledgments

The authors thank Dr. Nuria Thusius (Department of Psychiatry, Mayo Clinic) for her expertise and assistance with this manuscript, particularly regarding the implications for those on buprenorphine for OUD. The manuscript is dedicated in her loving memory.

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    Potential Competing Interests: Dr N.S. Warner receives research support from the Mayo Clinic Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery. Dr M.A. Warner receives research support from the Clinical and Translational Sciences Award (CTSA) Grant Number KL2 TR002379 from the National Center for Advancing Translational Sciences (NCATS). The remaining authors report no competing interests.

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