In the past few years I have noticed an increase in people using buprenorphine in various formulations for acute pain. I don’t know what others’ experiences have been but taking these people to the OR and trying to control their surgical pain is a disaster. Anyone have any advice? I’ve tried to explain to some of the services using this drug for acute pain that it makes it difficult down the road to treat these patients and that methadone would be a better alternative, but it hasn’t always gotten through.
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Buprenorphine
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Thankfully I’ve only seen it for chronic pain. Just remember that sufenta is the only common opioid we have with a stronger binding affinity for the mu receptor. Dilaudid is a tad weaker affinity but in the ballpark.
Follow the guidelines.
TBH I have found that if you titrate opioid to effect, you can still provide good analgesia through either fent or dilaudid to patients on bup. Just have to increase the dose. I think sometimes we get overly academic about the binding and potency, and to some degree bup is just another opioid like a fent patch.
Agree with you 100%. My intent was to highlight the potential relative increase of dose for these patients.
This isn’t really a guideline. The algorithm simply says “continue buprenorphine” and “consider an APS consult”. Duh. 🙄
I recently gave someone 8mg of dilaudid in a short period of time in addition to ketamine and a slew of other modalities. I have found for some people it simply doesn’t work.
Discontinue it beforehand if you can. Never seems to happen though and I don't know my patients until the night before.
Warn them in preop that their pain control will suck. You may get lucky and they will cancel the procedure themselves.
Schedule them early (before noon) if at ASC or just do them at the hospital. I would actually cancel them if they are scheduled to have a somewhat painful procedure at an ASC. I once waited 2 hours at the end of the day with a suboxone patient in PACU.
Offer regional if possible.
Can still give narcotics but also offer adjuncts like Tylenol, NSAID, ketamine, precedex. Can get fancy with Mg and lidocaine if you feel like.
Warn them in preop that their pain control will suck. You may get lucky and they will cancel the procedure themselves.
Schedule them early (before noon) if at ASC or just do them at the hospital. I would actually cancel them if they are scheduled to have a somewhat painful procedure at an ASC. I once waited 2 hours at the end of the day with a suboxone patient in PACU.
Offer regional if possible.
Can still give narcotics but also offer adjuncts like Tylenol, NSAID, ketamine, precedex. Can get fancy with Mg and lidocaine if you feel like.
That's just a few people's opinions published in non-peer-reviewed ASRA News. There is no prospective data on what to do. Just "expert" opinion and "experts" vary given their biases.
There is no right answer though. Individualized to the patient. If the patient is okay risking poorly controlled postop pain and other opioids not working much (at a dosage of >8-12mg/day), then continue it and hope for the best. If they have had bad experiences with postop pain and they are coming in for a significantly painful surgery, better to stop >48 hours in advance and bridge with a full agonist so they don't withdraw. If someone is more worried about relapse (than severe postop pain), then probably better to continue it. Chronic pain/outpatient prescribers will want you to continue it so they don't have to deal with the hassle of restarting it as an outpatient. They also don't have to deal with the 10/10 pain in the PACU after dilaudid 5mg in total has done nothing, so there's that.
I've been called too many times in the PACU for a consult for poorly controlled pain after no one thought to come up with a half-decent plan preoperatively. I get annoyed every time.
I'm not sure that's the result of the buprenorphine alone, maybe something else about the guy
Historically, it has been used to increase onset and duration of ISB.
Currently, I personally don’t use it in my practice in any form.
Like Suboxone, I think the current thinking is to continue it and titrate to effect like @Hoya11 mentioned.
