Cite as: Quaye A, Zhang Y. Letter to the editor: in response to “perioperative management of patients on buprenorphine for opioid use disorder.” ASRA Pain Medicine News 2023;48. https://doi.org/10.52211/asra080123.005.

We read with great interest the recent article; “Perioperative Management of Patients on Buprenorphine for Opioid Use Disorder,” written by Selvamani et al.¹ This article reviewed the complexities related to the perioperative management of patients on buprenorphine for opioid use disorder and provided the reader with recommendations on how to manage this medication. The topic addressed in this article is significant as there is continued controversy surrounding buprenorphine administration when acute pain is anticipated due to its pharmacological properties.^2-4

During the past five years, the discussion has shifted from the long-established practice of holding buprenorphine to facilitate opioid-based analgesia to continuing buprenorphine throughout the perioperative period, in part, due to the risk of relapse with abrupt discontinuation.^4-9 Nevertheless, despite the growing consensus that buprenorphine should not be routinely held, the optimal dosage of buprenorphine administration during the perioperative period remains uncertain as conclusive studies are lacking.⁴ This can lead to confusion for practitioners when determining the most appropriate management strategy for their patients.

In our recent national survey of institutions across the country, we identified significant variation in how buprenorphine is managed perioperatively.¹⁰ Additionally, this journal reaches disparate conclusions regarding published recommendations for buprenorphine management, even though the core evidence and supporting literature used to establish management conclusions have remained the same.^1,4,11 In Selvamani et al, the recommendation was to reduce the dose of buprenorphine to 16 mg in instances where moderate to severe pain was expected, consistent with recommendations from other authors.^4,7,9

However, in the expert panel practice guidelines published in 2021 entitled “ASRA Buprenorphine Guidance Provides Recommendations for Treating Patients with Known or Suspected Opioid Use Disorder,” the recommendation was to avoid the routine tapering of buprenorphine and continue the medication at a patient's basal dose in divided frequency with no distinction made based on pain anticipated. Tapering was only recommended “in isolated clinical circumstances such as high-level academic medical centers with excellent integration of addiction and acute pain services… in perioperative situations where extremely high levels of pain are anticipated and the admitting dose of buprenorphine is over 16 mg.”¹¹ The 2021 practice guidelines also recommended the option of increasing the dose of buprenorphine in instances when pain was difficult to manage, contradicting the 2023 guideline recommendations by Selvamani et al.¹¹

Currently, there is no high-level evidence to support the optimal perioperative management of buprenorphine, which is a significant concern given the increasing number of patients relying on this medication.¹² Our group is currently conducting a prospective trial in hopes of providing high-level evidence and establishing a consensus for managing these patients.¹³ However, we also believe that collaborations between multiple centers across different regions should be conducted to improve generalizability, given the significant disparate management practices that exist.

We appreciate the authors for bringing this significant debate to light. Despite the importance of administering buprenorphine during the perioperative period, current research on the optimal dose at which to continue buprenorphine needs to be supported to establish effective consensus protocols.

All the above options contribute to the barriers preventing standardized perioperative buprenorphine management. Patients often receive conflicting recommendations regarding the management of their medication, leading to uncertainty and reluctance to either continue or discontinue buprenorphine perioperatively. Although there is growing consensus that buprenorphine should not routinely be discontinued, some providers still follow this practice. Additionally, there is a lack of consensus regarding the appropriate dose and frequency of buprenorphine administration during the perioperative period.

Aurora Quaye, MD, is with Spectrum Healthcare Partners and is in the department of anesthesiology & perioperative medicine at the Maine Medical Center, both in Portland, ME, and is an assistant professor of anesthesia at Tufts University School of Medicine in Boston, MA.

Yi Zhang, MD, PhD, is with the department of anesthesia, critical care, and pain medicine at Massachusetts General Hospital and is an associate professor of anesthesia at Harvard Medical School, both in Boston, MA.

Address correspondence to:
Aurora Quaye, MD
aurora.quaye@spectrumhcp.com
Maine Medical Center, Department of Anesthesiology
22 Bramhall St, Portland ME 04102
(207) 200-4061

References

1. Selvamani BJ, Kral L, Swaran Singh T. Perioperative management of patients on buprenorphine for opioid use disorder. ASRA Pain Medicine News 2022; 47. https://doi.org/10.52211/asra020123.010
2. Anderson TA, Quaye ANA, Ward EN, et al. To stop or not, that is the question: acute pain management for the patient on chronic buprenorphine. Anesthesiology 2017;126:1180-86. https://doi.org/10.1097/aln.0000000000001633
3. Jonan AB, Kaye AD, Urman RD. Buprenorphine formulations: clinical best practice strategies recommendations for perioperative management of patients undergoing surgical or interventional pain procedures. Pain Physician 2018;21:E1-E12. https://doi.org/10.36076/PPJ.2018.1.E1
4. Quaye AN, Zhang Y. Perioperative management of buprenorphine: solving the conundrum. Pain Med 2019;20:1395-408. https://doi.org/10.1093/pm/pny217
5. Goel A, Azargive S, Lamba W, et al. The perioperative patient on buprenorphine: a systematic review of perioperative management strategies and patient outcomes. Can J Anaesth 2019;66:201-17. https://doi.org/10.1007/s12630-018-1255-3
6. Hickey T, Abelleira A, Acampora G, et al. Perioperative buprenorphine management: a multidisciplinary approach. Med Clin North Am 2022;106:169-85. https://doi.org/10.1016/j.mcna.2021.09.001
7. Lembke A, Ottestad E, Schmiesing C. Patients maintained on buprenorphine for opioid use disorder should continue buprenorphine through the perioperative period. Pain Med 2019;20:425-28. https://doi.org/10.1093/pm/pny019
8. Quaye A, Potter K, Roth S, et al. Perioperative continuation of buprenorphine at low-moderate doses was associated with lower postoperative pain scores and decreased outpatient opioid dispensing compared with buprenorphine discontinuation. Pain Med 2020;21:1955-60. https://doi.org/10.1093/pm/pnaa020
9. Warner NS, Warner MA, Cunningham JL, et al. A practical approach for the management of the mixed opioid agonist-antagonist buprenorphine during acute pain and surgery. Mayo Clin Proc 2020;95:1253-67. https://doi.org/10.1016/j.mayocp.2019.10.007
10. Quaye A, Mardmomen N, Mogren G, et al. Current state of perioperative buprenorphine management-a national provider survey. J Addict Med In Press
11. Kohan L, Potru S, Barreveld AM, et al. Buprenorphine management in the perioperative period: educational review and recommendations from a multisociety expert panel. Reg Anesth Pain Med 2021;46:840-59. https://doi.org/10.1136/rapm-2021-103007
12. Roehler DR, Guy GP, Jr., Jones CM. Buprenorphine prescription dispensing rates and characteristics following federal changes in prescribing policy, 2017-2018: A cross-sectional study. Drug Alcohol Depend 2020;213:108083. https://doi.org/10.1016/j.drugalcdep.2020.108083
13. Quaye A, Silvia K, Richard J, et al. A prospective, randomized trial of the effect of buprenorphine continuation versus dose reduction on pain control and post-operative opioid use. Medicine (Baltimore) 2022;101:e32309. https://doi.org/10.1097/MD.0000000000032309