Efficacy and Safety of Buprenorphine Transdermal Patch for Immediate Postoperative Analgesia After Total Knee Arthroplasty Surgery

Optimizing Safe Opioid Prescribing: A Paradigm Shift in Buprenorphine Management for Orthopedic Surgery

The worsening opioid epidemic in the United States, exacerbated by the COVID-19 pandemic, necessitates innovative approaches to pain management. Buprenorphine, a long-acting opioid, has gained popularity due to its safety profile and accessibility. Orthopaedic surgeons, encountering an increasing number of patients on buprenorphine, face challenges in peri-operative management. This article will update orthopaedic surgeons on new developments in the understanding of buprenorphine as a pain reliever and share evidence-based practice guidelines for buprenorphine management. For patients on buprenorphine for opioid use disorder or chronic pain, the updated recommendation is to continue their home dose of buprenorphine through the peri-operative period. The patient's buprenorphine prescriber should be contacted and notified of any impending surgery. The continuation of buprenorphine should be accompanied by a multimodal approach to analgesia, including a pre-operative discussion about expectations of pain and pain control, regional anesthesia, standing acetaminophen, Non-steroidal anti-inflammatory drugs (NSAIDs) when possible, gabapentinoids at night for patients under 65 years, cryotherapy, elevation, and early mobilization. Patients can also be prescribed short-acting, immediate release opioids for breakthrough pain. Transdermal buprenorphine (TDB) is emerging as an excellent option for the management of acute perioperative pain in both elective and non-elective orthopaedic patients. A single patch can provide a steady dose of pain medication for up to one week during the post operative period. A patch delivery method can help combat patient nonadherence and ultimately provide better overall pain control. In the future, TDB patches could be applied in virtually all fracture surgery, spinal surgery, total joint arthroplasty, ligament reconstructions with bony drilling, et cetera. As the stigma surrounding Buprenorphine decreases, further opportunities for perioperative use may develop.

The Efficacy of Buprenorphine in Preoperative and Postoperative Patients: A Literature Review

Although research suggests that less than half of individuals who have surgical procedures report effective postoperative pain alleviation, the majority of patients endure acute postoperative discomfort. To lessen and manage postoperative pain, a variety of preoperative, intraoperative, and postoperative treatments and management methods are available. For several years an opioid called buprenorphine has become an effective tool to treat opioid use disorder (OUD) in patients across many different demographics. It has however endured barriers to its usage which can be seen when treating patients with chronic pain or postoperative pain, who also have an OUD. While buprenorphine may be underutilized within the clinical setting, the significantly low rates of chronic abuse when using the drug allow it to be an attractive treatment option for patients. This paper aims to explore a wide range of studies that examine buprenorphine as an analgesic and how it can be used for preoperative pain and postoperative pain. This paper will give an in-depth analysis of buprenorphine and its use in patients with chronic pain as well as OUD. A systematic literature review was performed by identifying studies through the database PubMed. The data from various publications were gathered with preference being given to publications within the last three years. We reviewed studies that examined the pain level of the patients after having buprenorphine. Despite long-available pharmacologic evidence and clinical research, buprenorphine has maintained a mystique as an analgesic. Its usage in the treatment of OUD was further influenced by its well-known safety benefits and relative lack of psychomimetic side effects compared to other opioids. For patients accustomed to long-term, high-dose opioids who may be experiencing hyperalgesia but have not been informed about this phenomenon by their doctors or the potential for buprenorphine to resolve it, buprenorphine's pronounced antihyperalgesic effect is a compelling pharmacologic characteristic that makes it particularly attractive as an option. When used in pre-, peri-, and postoperative circumstances, buprenorphine provides various pain-management benefits and patients can still benefit from effective pain management from mu-opioid agonists while remaining on buprenorphine. Buprenorphine can be continued at a reduced dose as needed to avoid withdrawal symptoms and to improve the analgesic efficiency of mu-opioid agonists used in combination with acute postoperative pain in light of the evidence at hand. Buprenorphine administration needs a patient-centered, multidisciplinary strategy that considers the benefits and drawbacks of the many perioperative therapy options to have the best chance of success.

Iliopsoas plane block does not improve pain after primary total hip arthroplasty in the presence of multimodal analgesia: a single institution randomized controlled trial

BACKGROUND

The clinical analgesic efficacy of iliopsoas plane block remains a subject of discussion. This study aimed to assess the analgesic efficacy of iliopsoas plane block under general anesthesia using multimodal analgesia.

METHODS

Fifty-six adult patients who underwent elective primary hip arthroplasty were enrolled. Patients were randomized to receive either a single-shot iliopsoas plane block (10 mL 0.75% ropivacaine with 1:200 000 epinephrine) or a sham block (10 mL normal saline). All patients received general anesthesia, multimodal analgesia (preoperative buprenorphine patch, 5 µg/h), intraoperative intravenous dexamethasone (8 mg) and nefopam (20 mg), and round-the-clock acetaminophen and celecoxib. The primary outcome was the numeric rating scale pain score at rest 6 hour after surgery.

RESULTS

Iliopsoas plane block did not have a notable advantage over the sham block in terms of pain relief at rest, as assessed by the numeric rating scale score, 6 hour after total hip arthroplasty (iliopsoas plane block: median, 4.0; IQR, 2.0-5.8; sham: median, 5.5; IQR, 2.3-6.8; median difference, -1.0; 95% CI -2.0 to 0.0; p≥0.999). Linear mixed model analysis showed no differences in pain scores, opioid consumption, quadriceps strength, or quality of recovery between the groups.

CONCLUSIONS

Iliopsoas plane block did not improve postoperative analgesia following total hip arthroplasty under general anesthesia with a multimodal analgesic regimen. The blockade of sensory femoral branches supplying the anterior hip capsule using iliopsoas plane block may not yield additional benefits concerning patient outcomes in the aforementioned clinical context.

TRIAL REGISTRATION NUMBER

NCT05212038, https://clinicaltrials.gov/ct2/show/NCT05212038.

Efficacy and Safety of Transdermal Buprenorphine for Acute Postoperative Pain: A Systematic Review and Meta-analysis

Transdermal buprenorphine (TBUP) may have some advantages for the management of acute postoperative pain. The aim of this systematic review and meta-analysis was to investigate the efficacy and safety of TBUP compared to other analgesics or placebo for acute postoperative pain. A systematic search was conducted using Embase, MEDLINE, and Cochrane Central Register of Controlled Trials (CENTRAL) until December 26, 2022. The search included randomized controlled trials comparing TBUP versus other analgesics or placebo for acute postoperative pain. A certainty assessment was conducted using the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) method. The protocol for this review was registered on Prospective Register of Systematic Reviews (CRD42022318601). In total, 15 studies involving 1,205 participants were included that compared TBUP versus fentanyl (n = 2), celecoxib (n = 3), placebo (n = 2), tramadol (n = 5), diclofenac (n = 3), parecoxib (n = 1), and flurbiprofen (n = 1). Meta-analyses were conducted for 3 comparators that involved 2 studies each. There was no significant difference in pain between TBUP 10 mcg/h versus fentanyl 25 mcg/h (standardized mean difference [SMD] -.03, 95% confidence interval [CI] -.86 to .81, P = .95, I2 = 85%). TBUP 10 mcg/h was associated with less pain compared to celecoxib 200 mg twice daily (SMD -.32, 95% CI -.58 to -.05, P = .02, I2 = 0%) and placebo (SMD -2.29, 95% CI -4.32 to -.27, P = .03, I2 = 94%). The GRADE assessment showed a very low certainty of evidence for all comparisons. There is insufficient evidence that TBUP improves pain control compared to other analgesics for acute postoperative pain. PERSPECTIVE: This systematic review and meta-analysis compared the use of TBUP to other analgesics for postoperative pain. The results showed that there is insufficient evidence to recommend the use of TBUP in this setting. The findings will help clinicians select the most appropriate opioid regimens for postoperative pain.

Multimodal postoperative analgesia with transdermal buprenorphine is a safe option in arthroscopic rotator cuff repair

BACKGROUND

Arthroscopic rotator cuff repairs are associated with moderate-to-severe pain. Opioids are not the first line for postsurgical pain control due to their potential misuse and side effects. Transdermal buprenorphine represents an alternative for multimodal postoperative pain control.

METHODS

This was a single-centre, prospective longitudinal exploratory study of patients undergoing arthroscopic rotator cuff repairs managed with multimodal analgesia with transdermal buprenorphine. Patients were followed-up by telephone at eight time points, assessing pain levels, rescue analgesics requirement and side effects.

FINDINGS

Twenty-five patients with an average age of 63.4 ± 8.2 were included. Fourteen patients were ⩾65 years. Pain levels were similar among age groups at all time points, with no pain or mild pain (visual analogue scale 1-4) in most patients. The most frequent side effects were dizziness and somnolence.

CONCLUSION

Transdermal buprenorphine provided a sustained analgesic effect after an arthroscopic rotator cuff repair during the acute postsurgical period. It showed a similar safety profile among younger and older patients.

Comparison of the Transdermal and Intravenous Administration of Buprenorphine in the Management of Intra- and Postoperative Pain in Dogs Undergoing a Unilateral Mastectomy

The aim of this prospective clinical study was to evaluate the effectiveness of transdermal patches of buprenorphine as an alternative route for the management of perioperative pain in dogs undergoing a unilateral mastectomy. Our hypothesis was that the transdermal route would allow the obtainment of an analgesic plan comparable to that of the injectable administration. Twelve dogs were divided in two groups. In the BupreP group (six dogs), buprenorphine patches were applied 40 h before the start of the surgery, guaranteeing a dosage of 5−6 μg/kg/h. In the BupreI group (six dogs), 20 μg/kg of buprenorphine was administered intravenously 30 min before the induction of anesthesia, and this was repeated every 6 h for 24 h. The main physiological parameters, sedation scores (0 = no sedation; 11 = deep sedation), and pain scores were monitored from 30 min before the surgery to 24 h after the end of anesthesia. All p values < 0.05 were defined as statistically significant. Thirty minutes before the surgery, the sedation scores were higher in BupreI (score = 10) compared to the BupreP group (score = 1). Moreover, during the mastectomy, the mean arterial pressure significantly increased in both groups even if nobody required additional analgesia. In the postoperative period, the pain scores did not show statistically significant differences between the two groups, maintaining values below the pain threshold at all times of the study. In conclusion, the transdermal administration of buprenorphine could guarantee an analgesic quality equal to that of the injectable route.

Buprenorphine and its formulations: a comprehensive review

Buprenorphine, a novel long-acting analgesic, was developed with the intention of two purposes: analgesia and opioid use disorder. Regarding its pharmacodynamics, it is a partial agonist at mu receptors, an inverse agonist at kappa receptors, and an antagonist at delta receptors. For the purpose of analgesia, three formulations of buprenorphine were developed: IV/IM injectable formulation (Buprenex®), transdermal patch formulation (Butrans®), and buccal film formulation (Belbuca®). Related to opioid dependence, the formulations developed were subcutaneous extended release (Sublocade®), subdermal implant (Probuphine®), and sublingual tablets (Subutex®). Lastly, in order to avoid misuse of buprenorphine for opioid dependence, two combination formulations paired with naloxone were developed: film formulation (Suboxone®) and tablet formulation (Zubsolv®). In this review, we present details of each formulation along with their similarities and differences between each other and clinical considerations.

Comparison of Efficacy and Safety of Transdermal Buprenorphine Patch and Conventional Analgesics in Intra-capsular Femur Neck Fracture Post Hemiarthroplasty

BACKGROUND

One of the most common fractures in the elderly population is a fracture of the neck of femur. Effective post-operative analgesia is a major challenge. Age-related co-morbidities restrict the choice of analgesics. The purpose of this study was to compare the efficacy and safety of transdermal buprenorphine [TDB] patch and conventional analgesics following hemiarthroplasty for intra-capsular fracture neck of femur.

MATERIALS AND METHODS

This was a prospective, randomized control study done in 60 patients undergoing hemiarthroplasty for intra-capsular fracture neck of femur over a period of 2 years. Patients were randomized in 2 groups. Group A received a combination of IV paracetamol and tramadol for first 48 h followed by oral formulation. In Group B patients, a transdermal buprenorphine patch of 5 mcg/h was applied at the beginning of surgery and was continued 2 weeks post-operative.Pain score by VAS was observed both at rest and on movement and followed up till 14 days post-operative. Primary target was to maintain a VAS ≤ 4. Rescue analgesic was given if the VAS was ≥ 6. Secondary targets were number of rescue analgesics required, adverse reactions and complications if any.

RESULTS

Group B had significantly lower pain scores at rest and during movement [p value 0.0012 to ≤ 0.0001], so was rescue analgesia requirement. No significant side effects were seen in TDB group.

CONCLUSION

TDB patch is safe and provides superior analgesia and compliance as compared to conventional analgesics in the post-operative period in proximal femur fracture surgeries.

Transdermal Buprenorphine for Pain Management Following a Neck of Femur Fracture

Introduction

Pain management in patients with hip fractures can be challenging. Poor pain control is associated with reduced mobility and increased morbidity. Inadequate analgesia in patients with dementia is a concern. After using several different alternatives, transdermal buprenorphine was chosen as a standardised approach for analgesia in patients with fragility fracture in our hospital. There is limited evidence on the use of buprenorphine in this population. Our aim was to investigate the safety and effectiveness of transdermal buprenorphine in patients with hip fractures.

Methods

A review of consecutive patients presenting with a hip fracture from June 2018 to December 2018 was conducted using medical records. Our primary outcome was the incidence of complications as a consequence of transdermal buprenorphine. Our secondary outcome was adequate analgesia measured by reviewing the requirement for analgesia during the first week following the patient’s admission. Analgesia demands were considered adequate if patients required less than 20 mg of oral morphine in total during the first week following injury.

Results

In total, 148 patients presented with a hip fracture during the study period. 128 patients had documented evidence of buprenorphine patch application. Complete data was available for the primary outcome of complications in all cases. Data was available for the secondary outcome in 124 patients. Buprenorphine was discontinued in 24 patients (19%), most commonly due to due to concerns about contribution to hypoactive delirium (9%), and when strong analgesia was no longer required (4%). There were no severe complications. Adequate analgesia was achieved using this regime in 68% patients. 38 patients (32%) required more than 20 mg of oral morphine sulphate solution in the first week post-admission.

Conclusion

This series suggests that transdermal buprenorphine is safe and effective in the management of pain following a neck of femur fragility fracture.

Comparative evaluation of analgesic efficacy of buprenorphine transdermal patch and fentanyl patch in management of postoperative pain after arthroscopic lower limb surgery: A randomized controlled trial

Background and Aims

Transdermal opioids are newer modality in use for the control of postoperative pain, because of its noninvasiveness, longer duration of action, sustained blood levels, and with minimal side effects. The study was aimed to evaluate the efficacy of analgesia of buprenorphine patch 10, 20 μg·h^-1 and fentanyl patch 25 μg·h^-1 for relief of pain in the postoperative period in patients undergoing arthroscopic lower limb surgeries.

Materials and Methods

It was a randomized, double-blinded, prospective study in which adult patients undergoing lower limb arthroscopic surgery were randomly segregated into three groups. In Group 1 (fentanyl patch 25 μg·h^-1), Group 2 (buprenorphine patch 10 μg·h^-1), and Group 3 (buprenorphine patch 20 μg·h^-1), transdermal patches were applied 12 h prior to surgery. Mean NRS score, total rescue analgesic requirement, drug-related adverse effects, and hemodynamic status were evaluated till 72 h in the postoperative period.

Results

Out of 175 screened patients, 150 patients were finally analyzed. Baseline characteristics were the same among all the three groups. Median NRS score was lowest in Group 3 [P value < 0.05 at 2, 4, 8, 12, and 24 h after surgery (Kruskal Wallis test). The total consumption of postoperative rescue analgesic diclofenac was the lowest in Group 3 as compared to other groups without any significant increase in adverse events.

Conclusions

In arthroscopic lower limb surgery, buprenorphine patch (20 μg·h^-1) applied 12 h prior to surgery is an effective postoperative analgesic and it is not associated with any significant adverse effects.

Transdermal Buprenorphine for Acute Pain in the Clinical Setting: A Narrative Review

Transdermal buprenorphine is indicated for chronic pain management, but as its role in the clinical management of acute pain is less clear, this narrative review examines studies of the patch for acute pain, mainly in the postoperative setting. Although perhaps better known for its role in opioid rehabilitation programs, buprenorphine is also an effective analgesic that is a Schedule III controlled substance. Although buprenorphine is a partial agonist at the μ-opioid receptor, it is erroneous to think of the agent as a partial analgesic; it has full analgesic efficacy and unique attributes among opioids, such as a ceiling for respiratory depression and low “drug likeability” among those who take opioids for recreational purposes. Transdermal buprenorphine has been most thoroughly studied for acute pain control in postoperative patients. Postoperative pain follows a distinct and predictable trajectory depending on the type of surgery and patient characteristics. Overall, when the patch is applied prior to surgery and left in place for the prescribed seven days, it was associated with reduced postoperative pain, lower consumption of other analgesics, and patient satisfaction. Transdermal buprenorphine has been evaluated in clinical studies of patients undergoing gynecological surgery, hip fracture surgery, knee or hip arthroscopy/arthroplasty, shoulder surgery, and spinal surgery. Transdermal buprenorphine may also be appropriate pain medication for controlling pain during postsurgical orthopedic rehabilitation programs. Transdermal buprenorphine may result in typical opioid-associated side effects but with less frequency than other opioids. Despite clinical reservations about transdermal buprenorphine and its potential role in acute pain management in the clinical setting, clinical acceptance may be hampered by the fact that it is off-label and buprenorphine is better known as an opioid maintenance agent rather than an analgesic.

Comparative Evaluation of Efficacy of Preventive Analgesia with Diclofenac and Buprenorphine Patch versus Single Diclofenac Patch for Postoperative Pain following General Anesthesia for Laparoscopic Cholecystectomy

Background

Acute postoperative pain is managed with parenteral and oral medications requiring skilled personnel for administration and vigilance. Previous studies have been done either with transdermal buprenorphine or diclofenac patch separately in mitigating postoperative pain.

Aims

The primary aim was to compare pain scores and rescue analgesia requirement. The secondary aims were comparison of side effects, time to mobilization and oral intake start, sedation scores, and satisfaction scores of surgeons and patients receiving transdermal patches of buprenorphine and diclofenac versus placebo and diclofenac patches following laparoscopic cholecystectomy.

Settings and Design

This is a randomized double-blinded (1:1), case-control study.

Materials and Methods

One hundred patients undergoing laparoscopic cholecystectomies were enrolled for the study. Patients were allocated into two groups by computer-generated randomization: those receiving dual patch of buprenorphine and diclofenac (DP) and those receiving patches of diclofenac and placebo (SP). Outcomes were measured after extubation and at 4, 8, 12, 24, 36, and 48 h after surgery.

Statistics

Analysis was done using the Statistical Package for the Social Sciences version 22.0, R environment 3.2.2 for data analysis, and Microsoft Excel to generate graphs and tables.

Results

The pain scores and rescue analgesia requirements were significantly higher in group SP compared to group DP. Patient satisfaction scores were better with group DP. No significant difference was found in both the groups concerning sedation scores, side effects, and time to patient mobilization and start of oral intake.

Conclusions

Concomitant use of transdermal patches of buprenorphine and diclofenac for postoperative pain in laparoscopic cholecystectomy provides adequate analgesia and patient satisfaction without compromising postoperative recovery.