Surgery, buprenorphine, and patients in recovery from opioid use disorder

With the reintroduction of powerful narcotic opioids to manage acute pain, surgery can be a make-or-break time for patients in recovery from opioid use disorder (OUD). For those using buprenorphine as part of their recovery process, the stress, anxiety and risk can be amplified if, as is often the case, they are directed to stop using the buprenorphine ahead of their surgery.

With its new recommendations for management of buprenorphine for OUD in the perioperative setting, the American Society of Regional Anesthesia and Pain Medicine (ASRA) intends to ensure patients in recovery from OUD who undergo surgery continue to "make it" on their path of recovery and that those with suspected OUD are offered a bridge to treatment.

Against a backdrop of more than 93,000 overdose deaths—most of which involved opioids—in the United States in 2020, ASRA, along with the American Society of Anesthesiologists, American Academy of Pain Medicine, American Society of Addiction Medicine, and American Society of Health System Pharmacists have developed guidelines for continuing the use of buprenorphine in patients treating their OUD with the medication before and after surgery.

Two key findings in the literature search used to develop the guidelines are:

1. To decrease risk of OUD recurrence (i.e., relapse), buprenorphine should not be routinely discontinued in the perioperative setting; and
2. Buprenorphine can be initiated in untreated patients with OUD and acute pain in the perioperative setting to decrease the risk of opioid recurrence and death from overdose.

Although substantial evidence exists that buprenorphine is highly effective in treating OUD, historical recommendations for managing perioperative patients who are using buprenorphine for OUD may have been misguided. With concerns about an inability to effectively treat pain post-surgery if patients continue using buprenorphine during the perioperative period, many physicians have historically directed patients to discontinue buprenorphine before surgery. As practice has evolved, evidence now clearly supports the continued use of buprenorphine in perioperative patients. As the United States continues to seek solutions to the opioid overdose death epidemic, this is welcome news.

Stopping the use of buprenorphine in patients in recovery from OUD can be deadly. The combination of discontinuing buprenorphine and introducing narcotics like oxycodone to treat surgery-related acute pain can lead to relapse to active OUD. With the proliferation of fentanyl in the illicit drug market, any relapse to active OUD puts individuals at high risk of overdose death. In fact, the death rate for patients with OUD is highest within the first month after being discharged from the hospital.

As efforts to enlist more healthcare disciplines in identifying and treating OUD continue to increase, anesthesiologists and pain physicians are critical touchpoints in the system for supporting patients already in recovery from OUD but also in intervening with those suspected of OUD. The perioperative setting is an excellent opportunity to initiative life-saving buprenorphine treatment for those with active OUD.