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  • Writer's pictureDr. Harold Pierre

Should Patients Taking Buprenorphine Stop Before Surgery?

Updated: Dec 18, 2023

Should You Stop Buprenorphine Before Surgery?

The consensus is NO. Do not stop buprenorphine or Suboxone before surgery. This is a discussion that must occur with your addiction doctor and your surgeon. For my patients, the standard of care, the evidence-based data, and my experience of managing anesthesia and post-op pain for thousands of buprenorphine patients supports NEVER stopping buprenorphine. Please read to learn the particular details that are important.


Is Buprenorphine So Challenging to Manage Around Surgery?


Close up of scrub nurse taking medical instruments copy

Buprenorphine is a unique partial opioid agonist. It binds very tightly to the opioid receptors in the brain and does not easily disassociate, with effects lasting up to 3 days. This makes it very an effective treatment of opioid addiction and chronic pain.


However, theoretically this also blocks other opioids from binding to those receptors. Therefore, if opiates like morphine are administered to a patient taking buprenorphine, it may provide little pain relief after surgery. In the past, this has led many to believe that buprenorphine must be stopped before surgery to allow other opioids to work. However, the evidence demonstrates that other opioids continue to have an effect, especially for pain relief, even with buprenorphine doses as high as 32mg per day.


In fact, Greenwald et al (2014) revealed that even at buprenorphine doses of 16mg per day, 9 to 20% of mu receptors are available to bind with other opioids. At 32mg of buprenorphine per day, 6 to 12% of mu receptors are still unoccupied. Therefore, if buprenorphine blocks opioids, it doesn't block all of the receptors.


What Are the Risks of Stopping Buprenorphine Before Surgery?


Abruptly stopping buprenorphine in the stressful perioperative period risks precipitating acute opioid withdrawal and drug cravings. This can destabilize OUD treatment and trigger relapse in vulnerable patients. Is the surgeon ready to manage the withdrawal symptoms and the drug cravings?


In the recent 2022 review by Hickey et al, "Discontinuation of buprenorphine in the perioperative period places the patient at high risk for relapse and treatment dropout, which carries greater risk of overdose and death." Can you truly obtain informed consent for surgery in a patient in acute withdrawal? Probably not. Also, does it make sense to provide opioids to a person who may have a severe opioid use disorder? Again, probably not.


Emerging Evidence on Continuing Buprenorphine Perioperatively


Several studies over the past 15 years have demonstrated that continuing buprenorphine while also administering full opioid agonists can provide effective analgesia. As mentioned earlier, there are available opioid receptors at buprenorphine doses of 16mg or less. In addition, high doses of potent opioids like sufentanil, fentanyl, and hydromorphone can still bind enough receptors to offer pain relief. In the operating room, sufentanil is the drug of choice because its affinity for the mu receptor exceeds that of buprenorphine.


Hickey et al (2022) state: "Continuation of buprenorphine throughout the perioperative period with adjunct full opioid agonists as needed provides adequate analgesia while avoiding risks of buprenorphine discontinuation."


Perioperative Management of Patients Taking Buprenorphine


So what is the recommended approach today for perioperative management of a patient taking buprenorphine? The following are management strategies:

  • Use a multidisciplinary team including addiction medicine, anesthesia, pharmacy, etc. to coordinate acute perioperative pain control.

  • Standardize hospital protocols to continue taking buprenorphine perioperatively.

  • Administer full opioid agonists, preferably fentanyl or hydromorphone, concurrently as needed for analgesia.

  • As with any patient prescribed chronic opioids, consider buprenorphine patients opioid tolerant requiring higher than normal opioid doses.

  • Reduce opioid needs with regional anesthesia using nerve blocks and other opioid-sparing techniques.

  • Involve outpatient buprenorphine prescribers in planning.

  • Educate the patient thoroughly on the pain management plan.

  • Prescribe limited doses of opioids for a short duration after discharge.

  • Ensure close follow up care and renew buprenorphine quickly after discharge.

Benefits of This New Approach for Buprenorphine Management


This approach balances postoperative analgesia while avoiding buprenorphine discontinuation. It leverages buprenorphine's analgesic properties and maintains its OUD treatment benefits perioperatively when relapse risk is high. It is based on evidence-based medicine.


Compared to stopping buprenorphine before surgery, this strategy reduces opioid needs, shortens hospital stays, improves addiction treatment outcomes, and enhances patient safety.


Conclusion: A Patient-Centered Approach Is Key


Perioperative management for patients on buprenorphine remains complex. However, new evidence supports continuing buprenorphine while also administering full opioid agonists, within a structured multidisciplinary protocol. This emerging paradigm balances surgical pain relief with OUD treatment stability through coordinated, compassionate, patient-centered care.


References


Selvamani, B. J., Kral, L., & Swaran Singh, T. S. (2023, February 1). Perioperative management of patients on buprenorphine for opioid use disorder. ASRA Pain Medicine News, 47. https://doi.org/10.52211/asra020123.010


Greenwald MK, Comer SD, Fiellin DA. Buprenorphine maintenance and mu-opioid receptor availability in the treatment of opioid use disorder: implications for clinical use and policy. Drug Alcohol Depend 2014;144:1-11. https://doi.org/10.1016/j.drugalcdep.2014.07.035


Hickey T, Abelleira A, Acampora G, et al. Perioperative Buprenorphine Management: A Multidisciplinary Approach. Med Clin North Am. 2022;106(1):169-185. doi:10.1016/j.mcna.2021.09.001


Alford DP, Compton P, Samet JH. Acute pain management for patients receiving maintenance methadone or buprenorphine therapy. Ann Intern Med. 2006;144(2):127-134. doi:10.7326/0003-4819-144-2-200601170-00010


Anderson TA, Quaye ANA, Ward EN, Wilens TE, Hilliard PE, Brummett CM. To Stop or Not, That Is the Question: Acute Pain Management for the Patient on Chronic Buprenorphine. Anesthesiology. 2017;126(6):1180-1186. doi:10.1097/ALN.0000000000001633


About the author:

Dr. Harold Pierre is a board-certified anesthesiologist and addiction medicine specialist with over 20 years of experience. He is board-certified by the American Board of Anesthesiology and the American Board of Preventive Medicine.


This website is provided for educational and informational purposes only and does not constitute providing medical advice or professional services. The information provided should not be used for diagnosing or treating a health problem or disease, and those seeking personal medical advice should consult with a licensed physician or another qualified medical professional. Never disregard professional medical advice or delay in seeking it because of something you have read on this website.




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