Anesthetic Implications of Patients on Buprenorphine

Perioperative Management Strategies

The Society for Perioperative Assessment and Quality Improvement (SPAQI) recommends individualizing perioperative buprenorphine management based on patient-specific factors, such as prescribed daily dose, indication for treatment, risk of relapse, and expected level of postsurgical pain 1, 2, 3
The American College of Physicians and other medical societies suggest continuing buprenorphine therapy perioperatively, with consideration of tapering to 12 mg daily 2-3 days before surgery if high postoperative pain is anticipated, to minimize the risk of relapse and ensure adequate pain management 1, 4

Patients on buprenorphine may require higher doses of full mu-opioid agonists to achieve adequate analgesia due to partial blockade of opioid receptors, and multimodal analgesia should be maximized, including regional anesthesia techniques, non-opioid adjuncts, and local anesthetic infiltration by the surgeon 1, 5
The British Journal of Anaesthesia suggests that regional anesthesia techniques can be an effective way to manage pain in patients on buprenorphine, and should be considered when appropriate 5

The Mayo Clinic Proceedings recommends monitoring for potential drug-drug interactions that could result in QT-interval prolongation, serotonin syndrome, paralytic ileus, or precipitation of withdrawal symptoms, particularly when buprenorphine is combined with other CNS depressants 1
Concomitant use of buprenorphine with QT-prolonging agents is contraindicated, and patients with certain medical conditions, such as adrenal insufficiency, increased intracranial pressure, or impaired consciousness, require special consideration 1, 5

Abrupt discontinuation of buprenorphine in patients with opioid use disorder may precipitate withdrawal and increase risk of relapse, and coordination with the patient's buprenorphine provider is essential for perioperative planning and postoperative follow-up 5, 6

The British Journal of Anaesthesia recommends continuing buprenorphine at the preoperative dose in almost all circumstances for patients already on chronic buprenorphine therapy 7, 8
For patients on ≤12 mg sublingual daily, the British Journal of Anaesthesia suggests continuing the dose unchanged perioperatively 7, 8
For patients on >12 mg sublingual daily, consideration should be given to tapering to 12 mg sublingual 2-3 days before surgery if high postoperative pain is anticipated 7

The British Journal of Anaesthesia recommends implementing aggressive multimodal analgesia as the cornerstone of treatment, including regional anesthesia techniques and non-opioid adjuncts such as NSAIDs, acetaminophen, and ketamine 7, 8, 9
Full mu-opioid agonists at higher-than-normal doses (expect 2-4 times typical requirements) may be necessary for breakthrough pain due to buprenorphine's partial agonist activity creating competitive receptor blockade 7
Dividing the maintenance buprenorphine dose and administering every 6-8 hours rather than once daily can provide more consistent analgesia 7, 10

The World Journal of Emergency Surgery suggests monitoring respiratory status, sedation level, and pain scores regularly 9