To decrease the risk of opioid use disorder (OUD) recurrence in patients receiving hospital treatments, buprenorphine should not be routinely discontinued in the perioperative setting. Buprenorphine can be initiated in untreated patients with OUD and acute pain in the perioperative setting to decrease the risk of opioid recurrence and overdose death.

Those are the conclusions of new multidisciplinary guidance on managing patients with known or suspected OUD just been published by Regional Anesthesia & Pain Medicine.

OUD affects 2.5 million people in the United States, and the death rate is highest for patients with OUD in the first month after hospital discharge. Use of buprenorphine to treat OUD is effective and saves lives. As the authors emphasize, “Optimal analgesia can be obtained in patients with medication-treated OUD within the perioperative period. Anesthesiologists and pain physicians can recommend and consider initiating MOUD in patients with suspected opioid use disorder (OUD) at the point of care; this can serve as a bridge to comprehensive treatment and ultimately save lives.” 

Unfortunately, there are not enough buprenorphine prescribers, and information varies as to how to treat and manage patients already taking buprenorphine or suspected of having an OUD.

In 2020, ASRA led an effort to develop guidance for the use of buprenorphine by creating a Multisociety Working Group on Opioid Use Disorder, which represents the fields of pain medicine, addiction, and pharmacy health sciences. An extensive literature search and grading of evidence resulted in two core topics for development of recommendations: management of patients receiving buprenorphine MOUD in the perioperative setting and physician guidelines for starting buprenorphine in patients with suspected OUD in the perioperative setting.

The American Society of Anesthesiologists, American Society of Health-System Pharmacists, American Academy of Pain Medicine, and American Society of Addiction Medicine also participated in and approved the joint guidelines.

“Management of Buprenorphine for Opioid Use Disorder in the Perioperative Setting: Recommendations from the ASRA/ASA/ASHP/AAPM/ASAM Opioid Use Disorder Working Group” recommends that patients taking buprenorphine for OUD continue to do so at home prior to surgery because of the harm of discontinuation. In the postoperative setting, these patients can use multimodal analgesia and short-acting full mu agonists if needed. There is a low level of evidence supporting increasing or dividing the dose of buprenorphine in the postoperative setting. Upon discharge, physicians should provide patients with a taper plan and discuss the plan with the patient’s buprenorphine prescriber.

In patients with a suspected but untreated OUD, providers should consider starting buprenorphine for analgesia and provide a “warm hand-off” if possible. There is a low level of evidence supporting the preoperative initiation of buprenorphine even if follow-up has not been established.

Read the full article here.