Case Series of Successful Postoperative Pain Management in Buprenorphine Maintenance Therapy Patients

Consensus statement on pain management for pregnant patients with opioid use disorder from the Society for Obstetric Anesthesia and Perinatology, Society for Maternal-Fetal Medicine, and American Society of Regional Anesthesia and Pain Medicine

Pain management in pregnant and postpartum people with an opioid use disorder requires a balance among the risks associated with opioid tolerance, including withdrawal or return to opioid use, considerations around the social needs of the maternal-infant dyad, and the provision of adequate pain relief for the birth episode that is often characterized as the worst pain a person will experience in their lifetime. This multidisciplinary consensus statement from the Society for Obstetric Anesthesia and Perinatology, the Society for Maternal-Fetal Medicine, and the American Society of Regional Anesthesia and Pain Medicine provides a framework for pain management in obstetrical patients with opioid use disorder. The purpose of this consensus statement is to provide practical and evidence-based recommendations and is targeted to healthcare providers in obstetrics and anesthesiology. The statement is focused on prenatal optimization of pain management, labor analgesia and postvaginal delivery pain management, and postcesarean delivery pain management. Topics include a discussion of nonpharmacologic and pharmacologic options for pain management, medication management for opioid use disorder (eg, buprenorphine, methadone), considerations regarding urine drug testing and other social aspects of care for maternal-infant dyads, and a review of current practices. The authors provide evidence-based recommendations to optimize pain management while reducing risks and the complications associated with opioid use disorder in the peripartum period. Ultimately, this multidisciplinary consensus statement provides practical and concise clinical guidance to optimize pain management for people with opioid use disorder in the context of pregnancy to improve maternal and perinatal outcomes.

Consensus Statement on Pain Management for Pregnant Patients with Opioid-Use Disorder from the Society for Obstetric Anesthesia and Perinatology, Society for Maternal-Fetal Medicine, and American Society of Regional Anesthesia and Pain Medicine

Pain management in pregnant and postpartum people with an opioid-use disorder (OUD) requires a balance between risks associated with opioid tolerance, including withdrawal or return to opioid use, considerations around social needs of the maternal-infant dyad, and the provision of adequate pain relief for the birth episode that is often characterized as the worst pain a person will experience in their lifetime. This multidisciplinary consensus statement between the Society for Obstetric Anesthesia and Perinatology (SOAP), Society for Maternal-Fetal Medicine (SMFM), and American Society of Regional Anesthesia and Pain Medicine (ASRA) provides a framework for pain management in obstetric patients with OUD. The purpose of this consensus statement is to provide practical and evidence-based recommendations and is targeted to health care providers in obstetrics and anesthesiology. The statement is focused on prenatal optimization of pain management, labor analgesia, and postvaginal delivery pain management, and postcesarean delivery pain management. Topics include a discussion of nonpharmacologic and pharmacologic options for pain management, medication management for OUD (eg, buprenorphine, methadone), considerations regarding urine drug testing, and other social aspects of care for maternal-infant dyads, as well as a review of current practices. The authors provide evidence-based recommendations to optimize pain management while reducing risks and complications associated with OUD in the peripartum period. Ultimately, this multidisciplinary consensus statement provides practical and concise clinical guidance to optimize pain management for people with OUD in the context of pregnancy to improve maternal and perinatal outcomes.

Acute Pain Management in Traumatically Injured Patients With Outpatient Buprenorphine Therapy

INTRODUCTION

Acute pain management is challenging in trauma patients undergoing outpatient buprenorphine therapy at the time of injury due to the high binding affinity of this partial agonist. The purpose of this study was to evaluate acute pain management in admitted trauma patients with discontinued versus continued outpatient buprenorphine therapy.

MATERIALS AND METHODS

This retrospective study included adult trauma patients admitted to a level-1 trauma center between January 2017 and August 2020 who were receiving buprenorphine prior to admission. Groups were defined as buprenorphine discontinued (BD) or continued (BC) during hospitalization. The primary outcome compared median daily morphine milligram equivalents between groups. Secondary outcomes utilized patient-reported numeric rating scale (NRS) scores to compare incidences of no pain (NRS 0), mild (NRS 1-3), moderate (NRS 4-6), and severe (NRS 7-10) pain.

RESULTS

A total of 57 patients were included (BD 37 [64.9%] and BC 20 [35.1%]). The median (interquartile range) outpatient daily buprenorphine dose was similar between groups (8 [8-16] mg versus 16 [8-16], P = 0.25). Median daily morphine milligram equivalents was significantly higher during admission in the BD group (103.7 [80.7-166] versus 67 [30.8-97.4], P = 0.002). Incidence of no pain (7.1% versus 5.7%, P = 0.283), mild (5.5% versus 4.3%, P = 0.295), moderate (20.2%, 19.8%, P = 0.855), or severe (67.2% versus 70.2%, P = 0.185) pain was similar between BD and BC groups, respectively.

CONCLUSIONS

Continuation of outpatient buprenorphine therapy in acute trauma patients is associated with decreased daily opioid requirements and similar analgesic efficacy compared to patients with BD. Based on our findings, trauma patients receiving outpatient buprenorphine and not requiring ventilator support may benefit from buprenorphine continuation within 48 h of initial presentation.

Associations between postpartum pain type, pain intensity and opioid use in patients with and without opioid use disorder: a cross-sectional study

BACKGROUND

Pain is a multidimensional construct. The purpose of this cross-sectional, single-centre study was to evaluate the relationship between postpartum pain type with pain intensity and opioid use in people with and without opioid use disorder (OUD).

METHODS

Postpartum pain type was coded from McGill Pain Questionnaire and Patient-Reported Outcome Measurement Information System (PROMIS) inventories in people with or without OUD after childbirth in a 4-month period. The co-primary outcomes were pain intensity (0-10 scale) and total inpatient oxycodone (mg). Multivariable linear mixed-effects models assessed between- and within-person relationships for pain type (primary predictor) and outcomes.

RESULTS

There were 44 522 unique pain scores and types from 2610 people. Pain types were associated with pain intensity (P<0.001). Between-person comparisons showed affective pain was associated with a small but higher total oxycodone dose (difference 1.04 mg compared with no affective pain, P<0.001). Among people with OUD, within-person comparisons showed that the presence of affective pain resulted in pain scores 1 point higher than when affective pain was not present (P=0.002); between-person comparisons showed that people with affective pain had pain scores 6 points higher (P=0.048). Within-person and between-person comparisons among OUD showed that nociceptive/neuropathic pain was associated with a higher total oxycodone dose (1.6 and 11.4 mg, respectively).

CONCLUSIONS

Postpartum pain type was associated with pain intensity and opioid use. Further research is required to address the multiple dimensions of postpartum pain in people with and without OUD to improve treatment of postpartum pain.

A Systematic Scoping Review of Peridelivery Pain Management for Pregnant People With Opioid Use Disorder: From the Society for Obstetric Anesthesia and Perinatology and Society for Maternal Fetal Medicine

The prevalence of pregnant people with opioid use disorder (OUD), including those receiving medications for opioid use disorder (MOUD), is increasing. Challenges associated with pain management in people with OUD include tolerance, opioid-induced hyperalgesia, and risk for return to use. Yet, there are few evidence-based recommendations for pain management in the setting of pregnancy and the postpartum period, and many peripartum pain management studies exclude people with OUD. This scoping review summarized the available literature on peridelivery pain management in people with OUD, methodologies used, and identified specific areas of knowledge gaps. PubMed and Embase were comprehensively searched for publications in all languages on peripartum pain management among people with OUD, both treated with MOUD and untreated. Potential articles were screened by title, abstract, and full text. Data abstracted were descriptively analyzed to map available evidence and identify areas of limited or no evidence. A total of 994 publications were imported for screening on title, abstracts, and full text, yielding 84 publications identified for full review: 32 (38.1%) review articles, 14 (16.7%) retrospective studies, and 8 (9.5%) case reports. There were 5 randomized controlled trials. Most studies (64%) were published in perinatology (32; 38.1%) journals or anesthesiology (22; 26.2%) journals. Specific areas lacking trial or systematic review evidence include: (1) methods to optimize psychological and psychosocial comorbidities relevant to acute pain management around delivery; (2) alternative nonopioid and nonpharmacologic analgesia methods; (3) whether or not to use opioids for severe breakthrough pain and how best to prescribe and monitor its use after discharge; (4) monitoring for respiratory depression and sedation with coadministration of other analgesics; (5) optimal neuraxial analgesia dosing and adjuncts; and (6) benefits of abdominal wall blocks after cesarean delivery. No publications discussed naloxone coprescribing in the labor and delivery setting. We observed an increasing number of publications on peripartum pain management in pregnant people with OUD. However, existing published works are low on the pyramid of evidence (reviews, opinions, and retrospective studies), with a paucity of original research articles (<6%). Opinions are conflicting on the utility and disutility of various analgesic interventions. Studies generating high-quality evidence on this topic are needed to inform care for pregnant people with OUD. Specific research areas are identified, including utility and disutility of short-term opioid use for postpartum pain management, role of continuous wound infiltration and truncal nerve blocks, nonpharmacologic analgesia options, and the best methods to support psychosocial aspects of pain management.

Procedural moderate sedation in patients with opioid addiction and chronic pain: a practical primer for the radiologist

Opioid use disorder and chronic pain are increasingly commonly encountered in medicine and many patients now are prescribed medications (such as buprenorphine) to help treat these conditions. Many radiologists are unfamiliar with how these medications work and how they impact providing procedural sedation during procedures in the radiology department. The focus of this manuscript is to provide radiologists background and guidance on how these medications interact with medications given for procedural sedation and the appropriate management strategy for patients with opioid use disorder and chronic pain who require procedural sedation.

Peripartum and Postpartum Analgesia and Pain in Women Prescribed Buprenorphine for Opioid Use Disorder Who Deliver by Cesarean Section

Aim:

Little is known about whether pain can be effectively managed in pregnant women with opioid use disorder (OUD) during delivery hospitalization, particularly those undergoing surgery and taking buprenorphine as medication for OUD (MOUD). To address this question, we compared pain scores and opioid analgesic utilization during delivery hospitalization in women taking their pre-hospital dose of buprenorphine who delivered by cesarean section to matched controls. To inform future research efforts, we also began to explore opioid analgesic utilization and pain scores by type of anesthesia as this variable is often not included in related literature.

Methods:

Retrospective matched cohort study of 46 women prescribed buprenorphine during pregnancy who delivered by cesarean section during a 7-year period.

Results:

When compared to matched controls, women taking their pre-hospital dose of buprenorphine undergoing cesarean section utilized more opioid analgesics as measured by morphine milligram equivalents (MME) (mean MME first 48 hours 153.0 mg vs 175.1 mg, respectively, P < .01) but had similar pain scores during delivery hospitalization. There was no difference in MME utilization by maternal dose of buprenorphine though sample sizes were small. Women on buprenorphine who received spinal anesthesia with morphine had mean pain scores that were 1.4 points lower ( P = .01) during the first 48 hours than women on buprenorphine receiving other methods of anesthesia.

Discussion And Conclusions:

Pregnant women taking their pre-hospital dose of buprenorphine throughout their surgical delivery hospitalization were able to achieve pain relief similar to women not on MOUD but had higher MME requirements. Our results add to the emerging body of evidence suggesting that individuals on MOUD can achieve adequate post-surgical pain management without adjusting their pre-hospital dose of buprenorphine. Further research is required to fully understand the optimal buprenorphine dosing regimen during surgical hospitalizations. Our results also provide important preliminary evidence that spinal anesthesia containing opioids can be used effectively in individuals with OUD requiring surgical intervention.

Post-cesarean gabapentin is not associated with lower opioid consumption or pain scores in women on chronic buprenorphine therapy: A 10-year retrospective cohort study

STUDY OBJECTIVE

To determine if postoperative gabapentin administration is associated with decreased opioid consumption or pain scores following cesarean delivery in women on chronic buprenorphine.

DESIGN

Retrospective cohort study.

SETTING

Postoperative recovery area and postpartum inpatient unit.

PATIENTS

214 women undergoing cesarean delivery while on chronic buprenorphine at a single institution between 2007 and 2017.

INTERVENTIONS

Gabapentin treatment for post-cesarean analgesia.

MEASUREMENTS

The primary outcome was opioid consumption in morphine milligram equivalents, comparing patients who received ≥1 dose of gabapentin within 24 h of cesarean delivery to those who did not. Secondary outcomes included opioid consumption 24-48 and 48-72 h post-cesarean and postoperative numerical rating scale pain scores.

MAIN RESULTS

Of 214 included patients, 64 (30%) received gabapentin while 150 (70%) did not. Gabapentin patients were more likely than controls to have received neuraxial fentanyl (30% vs. 14%, p = 0.01) and transversus abdominis plane block (6% vs. 1%, p = 0.05) and overall received higher doses of ketorolac and acetaminophen. Control patients were more likely to have received neuraxial morphine (78% vs. 90%, p = 0.04) and received higher doses of ibuprofen. In unadjusted analysis, there was no significant difference in morphine milligram equivalent consumption 0-24 h postoperatively between gabapentin (55 mg [IQR 26,84]) and control (53 mg [IQR 28,75]) groups (p = 0.38). After controlling for potential confounders, there remained no significant effect of gabapentin administration (overall effect p = 0.99). Opioid consumption and pain scores were also not significantly different at any other time points.

CONCLUSIONS

In parturients receiving chronic buprenorphine, inclusion of gabapentin in a multimodal analgesic regimen was not associated with lower opioid consumption or pain scores during the first 72 h after cesarean delivery. Prospective randomized studies are needed to confirm these findings.

Post-Cesarean Delivery Analgesic Outcomes in Patients Maintained on Methadone and Buprenorphine: A Retrospective Investigation

Background

Despite the increasing prevalence of opioid use disorder (OUD) in pregnant women, there are limited studies on their anesthesia care and analgesic outcomes after cesarean delivery (CD).

Methods

Patients with OUD on either buprenorphine or methadone maintenance therapy who underwent CD at our institution from 2011 to 2018 were identified. Anesthetic details and analgesic outcomes, including daily opioid consumption and pain scores, were compared between patients maintained on buprenorphine and methadone. Analgesic outcomes were also evaluated according to anesthetic type (neuraxial or general anesthesia) and daily buprenorphine/methadone dose to determine if these factors impacted pain after delivery.

Results

A total of 146 patients were included (buprenorphine n=99 (67.8%), methadone n=47 (32.2%)). Among all patients: 74% had spinal/CSE, 15% epidural, and 11% general anesthesia. Anesthesia types were similar among buprenorphine and methadone patients. For spinal anesthetics, intrathecal fentanyl (median 15 µg) and morphine (median 100 µg) were commonly given (97.2% and 96.3%, respectively), and dosed similarly between groups. Among epidural anesthetics, epidural morphine (median 2 mg) was commonly administered (90.9%), while fentanyl (median 100 µg) was less common (54.5%). Buprenorphine and methadone groups consumed similar amounts of oxycodone equivalents per 24 hours of hospitalization (80.6 vs 76.3 mg; p=0.694) and had similar peak pain scores (8.3 vs 8.0; p=0.518). Daily methadone dose correlated weakly with opioid consumption (R=0.3; p=0.03), although buprenorphine dose did not correlate with opioid consumption or pain scores. General anesthesia correlated with greater oxycodone consumption in the first 24 hours (median 156.1 vs 91.7 mg; p=0.004) and greater IV PCA use (63% vs 7%; p<0.001) compared to neuraxial anesthesia.

Conclusion

Patients on buprenorphine and methadone had similar high opioid consumption and pain scores after CD. The anesthetic details and analgesic outcomes reported in this investigation may serve as a useful reference for future prospective investigations and aid in the clinical care of these patients.

Treating Perioperative and Acute Pain in Patients on Buprenorphine: Narrative Literature Review and Practice Recommendations

Opioid use disorder (OUD), a leading cause of morbidity and mortality in the USA, can be effectively treated with buprenorphine. However, the same pharmacologic properties (e.g., high affinity, partial agonism, long half-life) that make it ideal as a treatment for OUD often cause concern among clinicians that buprenorphine will prevent effective management of acute pain with full agonist opioid analgesics. Because of this concern, many patients are asked to stop buprenorphine preoperatively or at the onset of acute pain, placing them at high risk for both relapse and a difficult transition back to buprenorphine after acute pain has resolved. The purpose of this review is to summarize the existing literature for acute pain and perioperative management in patients treated with buprenorphine for OUD and to provide practical management recommendations for generalist practitioners based on evidence and clinical experience. In short, evidence suggests that sufficient analgesia can be achieved with maintenance of buprenorphine and use of both opioid and non-opioid analgesic options for breakthrough pain. We recommend that clinicians (1) continue buprenorphine in the perioperative or acute pain period for patients with OUD; (2) use a multi-modal analgesic approach; (3) pay attention to care coordination and discharge planning when making an analgesic plan for patients with OUD treated with buprenorphine; and (4) use an individualized approach founded upon shared decision-making. Clinical examples involving mild and severe pain are discussed to highlight important management principles.

Evidence for Continuing Buprenorphine in the Perioperative Period

OBJECTIVE

Given there are conflicting recommendations for the perioperative management of buprenorphine, we conducted a retrospective cohort study of our surgery patients on buprenorphine whose baseline dose had been preoperatively continued, tapered, or discontinued.

MATERIALS AND METHODS

We reviewed charts of patients on buprenorphine who had received elective surgery at Stanford Healthcare from January 1, 2013 to June 30, 2016. Our primary outcome of interest was the change in pain score, defined as mean postoperative pain score-preoperative pain score. We also collected data on patients' tapering procedure and any postoperative nonbuprenorphine opioid requirements.

RESULTS

Out of ∼1200 patients on buprenorphine, 121 had surgery of which 50 were admitted and included in the study. Perioperative continuation of transdermal buprenorphine resulted in a significantly lower change in pain score postoperatively (0.606±0.878) than discontinuation (4.83±1.23, P=0.012). Among sublingual patients, there was no statistically significant difference in the change in pain score between those who were tapered to a nonzero dose versus discontinued (P=0.55). Continuation of sublingual buprenorphine resulted in fewer nonbuprenorphine scheduled opioid prescriptions than its taper or discontinuation (P=0.028). Finally, tapers were performed with great variability in the tapering team and rate of taper.

DISCUSSION

On the basis of our findings, we implemented a policy at our institution for the continuation of perioperative buprenorphine whenever possible. Our work reveals crucial targets for the education of perioperative healthcare providers and the importance of coordination among all perioperative services and providers.

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

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).

Buprenorphine management: a conundrum for the anesthesiologist and beyond - a one-act play

We have witnessed a worldwide upsurge of streamlined enhanced recovery after surgery (ERAS) pathways advocating for consistency and compliance within their guidelines. At a recent national conference, two experts defended their institutional policies on perioperative management of buprenorphine, one defending its continuation, while the other suggesting its discontinuation. The moderator diplomatically proclaimed the need to have guidance at the institutional level and following it for favorable patient outcomes. Unfortunately, perioperative management of buprenorphine remains an understudied topic with a lack of national guidelines leading to variations at a local level despite its increased use nationally in the current opioid crisis. Although the moderator made a valid statement, we demonstrate via our one-act play the importance of recognizing a subset of the population within an ERAS pathway that necessitates multidisciplinary discussion, communication, and patient-centric care to formulate a perioperative plan coordinating a patient's care. More robust research is needed to minimize variability in current practices and to further develop comprehensive evidence-based guidelines that encompass risk factors and anticipated postsurgical and peripartum pain for patients on buprenorphine.

Continuous Epidural Hydromorphone Infusion for Post-Cesarean Delivery Analgesia in a Patient on Methadone Maintenance Therapy: A Case Report

The prevalence of opioid use disorder (OUD) in the United States has more than quadrupled over the past two decades. This patient population presents a number of challenges to clinicians, including difficult pain management after surgical procedures due to the development of opioid tolerance. Significantly greater opioid consumption and pain scores after cesarean delivery have been reported in patients with OUD compared to other obstetric patients. A multi-modal analgesic regimen is generally recommended, but there are few well-established pain management strategies after cesarean delivery specific to patients with OUD. We present the case of a patient with OUD maintained on daily methadone that received a continuous epidural hydromorphone infusion for post-cesarean analgesia, a technique not previously reported in obstetric patients and only rarely described for patients undergoing other surgical procedures. The patient received epidural anesthesia for cesarean delivery, and after surgery, the epidural catheter was left in place for the epidural hydromorphone infusion, initiated at 140 mcg/hr and continued for approximately 40 hrs. This strategy reduced her average daily oral opioid consumption by 97%, reduced self-reported pain scores, shortened the length of hospitalization and improved ability to ambulate compared to her previous cesarean delivery. The use of continuous epidural hydromorphone infusion was effective in this case, and this analgesic technique may also be applicable to other types of surgical procedures with the potential for significant post-operative pain, particularly in patients with OUD.

Perioperative Management of a Patient Taking Suboxone® at the Time of Ambulatory Surgery

In 2016, more than 11 million people reported misuse of opioids in the previous year. In an effort to combat opioid use disorder (OUD), the use of agonist/antagonist is becoming increasingly common, with more than 2.2 million patients reporting use of a buprenorphine containing medication such as Suboxone®. Buprenorphine is a unique opioid which acts as a partial μ agonist and ĸ antagonist. These properties make it an effective tool in treating OUD and abuse. However, despite its advantages in treating OUD and abuse, buprenorphine can make it difficult to control acute perioperative pain. We present a case in which the Mayo Clinic Arizona protocol for patients undergoing minimally invasive ambulatory surgery while taking Suboxone® is successfully executed, resulting in adequate postoperative pain control and timely discharge from the postanesthesia recovery unit.

Understanding Buprenorphine for Use in Chronic Pain: Expert Opinion

OBJECTIVE

An expert panel convened to reach a consensus on common misconceptions surrounding buprenorphine, a Schedule III partial µ-opioid receptor agonist indicated for chronic pain. The panel also provided clinical recommendations on the appropriate use of buprenorphine and conversion strategies for switching to buprenorphine from a full µ-opioid receptor agonist for chronic pain management.

METHODS

The consensus panel met on March 25, 2019, to discuss relevant literature and provide recommendations on interpreting buprenorphine as a partial µ-opioid receptor agonist, prescribing buprenorphine before some Schedule II, III, or IV options, perioperative/trauma management of patients taking buprenorphine, and converting patients from a full µ-opioid receptor agonist to buprenorphine.

RESULTS

The panel recommended that buprenorphine's classification as a partial µ-opioid receptor agonist not be clinically translated to mean partial analgesic efficacy. The panel also recommended that buprenorphine be considered before some Schedule II, III, or IV opioids in patients with a favorable risk/benefit profile on the basis of metabolic factors, abuse potential, and tolerability and that buprenorphine be continued during the perioperative/trauma period. In addition, switching patients from a full µ-opioid receptor agonist to buprenorphine should be considered with no weaning period at starting doses that are based on the previous opioid dose.

CONCLUSIONS

These recommendations provide a framework for clinicians to address most clinical scenarios regarding buprenorphine use. The overall consensus of the panel was that buprenorphine is a unique Schedule III opioid with favorable pharmacologic properties and a safety profile that may be desirable for chronic pain management.

Perioperative Pain Management for Median Sternotomy in a Patient on Chronic Buprenorphine/Naloxone Maintenance Therapy: Avoiding Opioids in Patients at Risk for Relapse

The opioid crisis in the United States has been pandemic. As such, anesthesia providers are frequently faced with patients who have a history of opioid abuse or are currently receiving chronic therapy for such disorders. The chronic administration of medications such as buprenorphine-naloxone can impact the choice of perioperative anesthesia and pain control. Furthermore, the postoperative administration of opioids may lead to relapse in patients with a history of opioid abuse. We present a 26-year-old male with a history of opioid abuse on maintenance therapy with buprenorphine-naloxone, who presented for median sternotomy, cardiopulmonary bypass, and pulmonary valve replacement. The perioperative implications of buprenorphine-naloxone and implementation of multimodal analgesia are discussed, along with options to decrease or eliminate the perioperative use of opioids.

Acute Experimental Pain Responses in Methadone- and Buprenorphine/Naloxone-Maintained Patients Administered Additional Opioid or Gabapentin: A Double-Blind Crossover Pilot Study

Objective

The study objective was to identify the analgesic efficacy of three different pharmacological strategies in patients receiving methadone or buprenorphine as opioid agonist treatment (OAT). The three pharmacological approaches, a) increasing maintenance methadone/buprenorphine dose by 30%, b) adding oxycodone, or c) adding a single dose of gabapentin, were compared with a control condition of the participant’s usual OAT dose.

Design

A randomized, controlled, double-blinded, double-dummy, within-subject crossover study.

Subjects

Nine participants on stable doses of methadone and eight participants on stable doses of buprenorphine were recruited.

Setting

An outpatient opioid treatment clinic in inner city Sydney, Australia.

Methods

The cold pressor tolerance test was used to examine experimental pain threshold and tolerance. Ratings of subjective drug effects and safety measures (physiological and cognitive) were assessed.

Results

There was no difference in the primary outcome measures of pain thresholds or tolerance between the conditions examined. Interindividual variability was evident. Differences in some subjective measures were identified, including lower pain recall, lower “bad effects,” and higher global satisfaction in the additional methadone condition. In the buprenorphine arm, increased drug liking and “bad effects” were detected with oxycodone administration, while increased subjective intoxication was identified with gabapentin.

Conclusions

There was no evidence of an objective improvement in analgesia with any condition compared with control. Further research is required to optimize pain management strategies in this population.

Managing Opioid Use in Orthopaedic Patients Through Harm Reduction Strategies

Opioids are commonly prescribed in orthopaedics for acute or chronic pain for a variety of conditions, including injury, trauma, degenerative processes, and postsurgical. Patients who are taking opioids because of a substance use disorder (SUD) are also seen in orthopaedics. Patients who are prescribed opioids are at risk of developing an opioid use disorder (OUD). Ten percent of Americans will develop an SUD, which is considered a chronic medical condition that develops due to an imbalance in brain chemistry. In studies, orthopaedic surgeons have a high rate of prescribing opioids, but this rate is decreasing along with national average due to public and provider awareness of the opioid epidemic and professional recommendations. Despite the evidence of a neurobiological cause for SUDs, stigma toward patients with SUDs and a knowledge deficit are common among healthcare professionals, including orthopaedic nurses. A harm reduction approach when working with orthopaedic patients taking opioids either prescribed or used because of an OUD can be applied to reduce the problematic effects of opioids. Harm reduction strategies are supportive to the patient and include education and prevention, adopting evidence-based treatment and communication strategies, and the use of naloxone to prevent opioid overdose.

Anesthesia considerations and post-operative pain management in pregnant women with chronic opioid use

The prevalence of opioid use disorder in pregnancy has escalated markedly in recent years. Chronic opioid use during pregnancy poses several challenges for providing adequate analgesia and anesthesia in the peripartum period. These challenges include the potential for withdrawal, opioid tolerance and opioid-induced hyperalgesia. Here we discuss alterations in analgesic pharmacokinetics and pharmacodynamics that are associated with chronic opioid use. In addition, when treating pain in patients with opioid use disorder it is important to distinguish between different subgroups. In this review, we will discuss practical management strategies for parturients with (1) untreated opioid use disorder, (2) parturients on medication-assisted treatment (methadone, buprenorphine) and (3) patients recovering from opioid use disorder that are currently abstinent. Finally, we offer an overview of non-opioid strategies that may be utilized as part of a multimodal approach to providing optimal analgesia in this patient population.

Perioperative Considerations for the Patient with Opioid Use Disorder on Buprenorphine, Methadone, or Naltrexone Maintenance Therapy

As part of a national effort to combat the current US opioid epidemic, use of currently Food and Drug Administration-approved drugs for the treatment of opioid use disorder/opioid addiction (buprenorphine, methadone, and naltrexone) is on the rise. To provide optimal pain control and minimize the risk of relapse and overdose, providers need to have an in-depth understanding of how to manage these medications in the perioperative setting. This article reviews key principles and discusses perioperative considerations for patients with opioid use disorder on buprenorphine, methadone, or naltrexone.

Treating Chronic Pain: An Overview of Clinical Studies Centered on the Buprenorphine Option

The buprenorphine receptor binding profile is unique in that it binds to all three major opioid receptors (mu, kappa, delta), and also binds to the orphan-like receptor, the receptor for orphanin FQ/nociceptin, with lower affinity. Within the mu receptor group, buprenorphine analgesia in rodents is dependent on the recently discovered arylepoxamide receptor target in brain, which involves a truncated 6-transmembrane mu receptor gene protein, distinguishing itself from morphine and most other mu opioids. Although originally designed as an analgesic, buprenorphine has mainly been used for opioid maintenance therapy and only now is increasingly recognized as an effective analgesic with an improved therapeutic index relative to certain potent opioids. Albeit a second-, third-, or fourth-line analgesic, buprenorphine is a reasonable choice in certain clinical situations. Transdermal patches and buccal film formulations are now commercially available as analgesics. This review discusses buprenorphine pharmacodynamics and pharmacokinetics, use in certain populations, and provides a synopsis of systematic reviews and randomized analgesic trials. We briefly discuss postoperative management in patients receiving buprenorphine maintenance therapy, opioid equivalence to buprenorphine, rotations to buprenorphine from other opioids, and clinical relevance of buprenorphine-related QTc interval changes.

Management of eight labor and delivery patients dependent on buprenorphine (Subutex™): A retrospective chart review

Background: Opioid use during pregnancy is a growing concern in the United States. Buprenorphine has been recommended by “The American College of Obstetrics and Gynecology” as an alternative to methadone to decrease risks associated with the use of illicit opioids during pregnancy. The partial μ-opioid agonists’ unique pharmacology, including its long half time and high affinity to the μ-opioid receptor, complicates patient management in a highly kinetic, and often urgent field like obstetric anesthesia. We reviewed our management and outcomes in this medically complex population.

Methods: An Institutional Review Board (IRB) approved retrospective chart review was conducted of women admitted to the University of Washington Medical Center Labor and Delivery unit from July 2012 to November 2013 using buprenorphine. All deliveries, including intrauterine fetal demise, were included.

Results: Eight women were admitted during this period to our L&D floor on buprenorphine. All required peri-partum anesthetic management either for labor and/or cesarean delivery management. Analgesic management included dilaudid or fentanyl PCA and/or continued epidural infusion, and in one instance ketamine infusion, while the pre-admission buprenorphine regimen was continued. Five babies were viable, two women experienced intrauterine fetal death at 22 and 36 weeks gestational age (GSA), respectively, and one neonate died shortly after delivery due to a congenital diaphragmatic hernia.

Conclusions: This case series illuminates the medical complexity of parturients using buprenorphine. Different treatment modalities in the absence of evidence-based guidelines included additional opioid administration and continued epidural analgesia. The management of post-cesarean pain in patients on partial μ-opioid agonists remains complex and variable, and evidence-based guidelines could be useful for clinicians to direct care.

Management of eight labor and delivery patients dependent on buprenorphine (Subutex™): A retrospective chart review

Background: Opioid use during pregnancy is a growing concern in the United States. Buprenorphine has been recommended by "The American College of Obstetrics and Gynecology" as an alternative to methadone to decrease risks associated with the use of illicit opioids during pregnancy. The partial μ-opioid agonists' unique pharmacology, including its long half time and high affinity to the μ-opioid receptor, complicates patient management in a highly kinetic, and often urgent field like obstetric anesthesia. We reviewed our management and outcomes in this medically complex population. Methods: An Institutional Review Board (IRB) approved retrospective chart review was conducted of women admitted to the University of Washington Medical Center Labor and Delivery unit from July 2012 to November 2013 using buprenorphine. All deliveries, including intrauterine fetal demise, were included. Results: Eight women were admitted during this period to our L&D floor on buprenorphine. All required peri-partum anesthetic management either for labor and/or cesarean delivery management. Analgesic management included dilaudid or fentanyl PCA and/or continued epidural infusion, and in one instance ketamine infusion, while the pre-admission buprenorphine regimen was continued. Five babies were viable, two women experienced intrauterine fetal death at 22 and 36 weeks gestational age (GSA), respectively, and one neonate died shortly after delivery due to a congenital diaphragmatic hernia. Conclusions: This case series illuminates the medical complexity of parturients using buprenorphine. Different treatment modalities in the absence of evidence-based guidelines included additional opioid administration and continued epidural analgesia. The management of post-cesarean pain in patients on partial μ-opioid agonists remains complex and variable, and evidence-based guidelines could be useful for clinicians to direct care.