The article, “Perioperative Management of Extended-Release Buprenorphine: A Narrative Review and Case Series” has been published in SAj in Volume 44 Issue 1-2.
In this commentary, the authors state perioperative management of formulations of buprenorphine used for the treatment of opioid use disorder and/or pain are common clinical challenges. Care strategies are increasingly recommending continuation of buprenorphine while administering multimodal analgesia including full agonist opioids. While this “simultaneous strategy” is relatively simple for the shorter-acting sublingual buprenorphine formulation, best practices are needed for the increasingly prescribed extended-release buprenorphine (ER-buprenorphine). The authors state that, to their knowledge, there are no prospective data to guide perioperative management of patients on ER-buprenorphine. They provide a narrative review, report on the perioperative experiences of a series of patients maintained on ER-buprenorphine, and propose recommendations for perioperative ER-buprenorphine management based on best evidence, clinical experience, and their judgments.
In the AUTHORS’ OWN WORDS, they relate the importance of their work:
“There is a paucity of literature and guidance on how to address patients on ER-buprenorphine who require either acute pain treatment or elective/urgent operative care. We identified only 1 published case report describing the perioperative management of a patient on ER-buprenorphine undergoing elective surgery; in that case the patient successfully underwent major surgeries utilizing a strategy of performing the surgeries at the time of the next scheduled dose.”
“This evidence void lends itself to large variations in practice. Even in the case of sublingual buprenorphine, where perioperative continuation has become the consensus strategy, two-thirds of patients in a large healthcare system had their buprenorphine doses withheld preoperatively as recently as 2018.”
“Here we have described several management strategies which are unsurprisingly quite diverse and met with varying degrees of success. These cases clearly do not support any particular strategy; more so they illustrate the lack of an established uniform approach. Recognizing the absence of strong supporting data and extrapolating from clinical experience and the limited data described herein, we propose the following general overarching principles to guide clinicians of perioperative patients with steady state levels of ER-buprenorphine. These are applicable to both elective and emergent surgeries.”