Commentary on the current state of perioperative and critical care buprenorphine management

For over two decades, the United States has grappled with our current opioid use disorder (OUD) epidemic [1]. In response, there has been a significant increase in the utilization of buprenorphine for OUD treatment, in part because of its distinctive pharmacologic properties [2, 3]. Compared to other opioids, buprenorphine has a long half-life, high binding affinity and slow dissociation from opioid receptors. Therefore, it resists displacement from these receptors when other opioids are used in conjunction [4]. The therapeutic doses of buprenorphine used for chronic pain treatment are significantly lower than those required for OUD treatment; therefore, opioid receptors are available when additional opioids are used concomitantly to enhance analgesia [5]. Conversely, when buprenorphine is used for OUD treatment, the diminished availability of opioid receptors resulting from the higher buprenorphine doses required can pose challenges for analgesic management [6]. Although routine practice involves continuing chronic pain buprenorphine formulations when acute pain is anticipated, the prevailing practice until recently has been withholding OUD dosed buprenorphine [4, 7]. Emerging evidence challenges these notions and supports opioid based analgesia can be achieved in parallel with OUD buprenorphine continuation [5, 8, 9].

In our previous retrospective study of surgical patients with OUD comparing patients where buprenorphine was continued or discontinued, we identified significantly higher outpatient opioid dispensing with buprenorphine discontinuation [5]. Similar findings were reported by Li et al., [8] where patients who continued buprenorphine perioperatively at various tapered doses received significantly fewer opioid prescriptions compared to those where buprenorphine was discontinued.

Despite these studies, our recent national survey revealed significant variation in perioperative buprenorphine management practices [10]. Among surveyed anesthesiologists, only 36% of institutions had a protocol for buprenorphine management, and over a third endorsed either discontinuing buprenorphine in situations where moderate to severe pain was anticipated or adopting inconsistent management practices because of the lack of an institutional protocol. Premature discontinuation of buprenorphine is associated with an increased risk of opioid-induced relapse, making such practices concerning [11, 12].

The lack of clear guidance for buprenorphine management also extends to the critical care community. The 2018 Clinical Practice Guidelines for the Prevention and Management of Pain, Agitation/Sedation, Delirium, Immobility and Sleep Disruption in Adult Patients in the Intensive Care Unit did not provide recommendations for managing buprenorphine in patients maintained on this medication [13]. In our retrospective study evaluating the relationship between opioid exposure and buprenorphine administration in the intensive care unit, we identified the odds of receiving additional opioids were more than six times higher on days when buprenorphine was not administered compared to when it was given [14]. These findings support continuation of buprenorphine during critical illness, as it is associated with significantly decreased use of supplemental opioids, similar to current best practice established for perioperative populations.

The above information reveals that high-level evidence on the analgesic outcomes based on buprenorphine management need to be conducted to establish a consensus for managing patients maintained on this medication [15]. In the face of the opioid crisis, evidence-based practices are crucial to guide clinicians and policymakers in providing the best possible care for patients maintained on buprenorphine.

Aurora Quaye: Conceptualization (lead); investigation (equal); writing—original draft (lead); writing—review and editing (equal). Charlotte Crist: Conceptualization (supporting); investigation (supporting); writing—original draft (supporting); writing—review and editing (supporting). Simba Matoi: Conceptualization (supporting); investigation (supporting); writing—original draft (supporting); writing—review and editing (supporting). Yi Zhang: Conceptualization (equal); investigation (equal); writing—original draft (equal); writing—review and editing (equal).

None.