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Brighton T, Bagchi A, Fernandez J, Ashton S, Angaramo G, Ha M. Perioperative Management of Buprenorphine at an Urban Academic Medical Center. J Surg Res 2024; 302:160-165. [PMID: 39098114 DOI: 10.1016/j.jss.2024.06.024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2023] [Revised: 05/24/2024] [Accepted: 06/23/2024] [Indexed: 08/06/2024]
Abstract
INTRODUCTION Buprenorphine is a partial mu opioid receptor agonist with high affinity to its receptor, which raises concerns of blocking or displacing full opioid agonists when used during the perioperative period of surgical patients. However, buprenorphine itself has high analgesic potency and discontinuing buprenorphine may lead to suboptimal pain control and risk for opioid use disorder relapse. There is limited data for the continuation of buprenorphine perioperatively. METHODS This study is a retrospective cohort study of adult surgical patients taking buprenorphine for opioid use disorder at an urban, teaching, level 1 trauma center. Patients were split into two groups based on whether buprenorphine was continued (n = 46) or held (n = 28) within the first 48 h after surgery. RESULTS Those who had buprenorphine continued in the first 48 h postoperatively required half the dose of nonbuprenorphine opioids compared to those who had buprenorphine held (113.25 versus 255.75 oral morphine equivalents, P = 0.0040). Both groups had a similar level of analgesia and incidence of adverse events. Nearly all patients who continued buprenorphine in the first 48 h postoperatively were discharged on this agent, while only half of patients who had buprenorphine held were restarted on it at discharge (92.68% versus 56.52%, P = 0.0013). CONCLUSIONS This present study found lower nonbuprenorphine opioid requirements in patients with continued versus held perioperative buprenorphine use with no difference in degree of analgesia.
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Affiliation(s)
- Tessa Brighton
- Department of Pharmacy Services, University of Massachusetts Memorial Medical Center, Worcester, Massachusetts; University of Massachusetts Medical School, Worcester, Massachusetts.
| | - Avilash Bagchi
- Department of Pharmacy Services, University of Massachusetts Memorial Medical Center, Worcester, Massachusetts; University of Massachusetts Medical School, Worcester, Massachusetts
| | - Juliet Fernandez
- Department of Anesthesiology & Perioperative Medicine, University of Massachusetts Medical School, Worcester, Massachusetts
| | - Suzanne Ashton
- Department of Anesthesiology & Perioperative Medicine, University of Massachusetts Medical School, Worcester, Massachusetts
| | - Gustavo Angaramo
- Department of Anesthesiology & Perioperative Medicine, University of Massachusetts Medical School, Worcester, Massachusetts
| | - Michael Ha
- Department of Pharmacy Services, University of Massachusetts Memorial Medical Center, Worcester, Massachusetts
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Liu O, Leon D, Gough E, Speed T, Hanna M, Jaremko K. A retrospective analysis of perioperative medications for opioid-use disorder and tapering additional postsurgical opioids via a transitional pain service. Br J Clin Pharmacol 2024. [PMID: 38817150 DOI: 10.1111/bcp.16118] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2024] [Revised: 04/19/2024] [Accepted: 04/27/2024] [Indexed: 06/01/2024] Open
Abstract
AIMS To investigate perioperative opioid requirements in patients on methadone or buprenorphine as medication for opioid-use disorder (MOUD) who attended a transitional pain clinic (Personalized Pain Program, PPP). METHODS This retrospective cohort study assessed adults on MOUD with surgery and attendance at the Johns Hopkins PPP between 2017 and 2022. Daily non-MOUD opioid use over 6 time-points was evaluated with regression models controlling for days since surgery. The time to complete non-MOUD opioid taper was analysed by accelerated failure time and Kaplan-Meier models. RESULTS Fifty patients (28 on methadone, 22 on buprenorphine) were included with a median age of 44.3 years, 54% male, 62% Caucasian and 54% unemployed. MOUD inpatient administration occurred in 92.8% of patients on preoperative methadone but only in 36.3% of patients on preoperative buprenorphine. Non-MOUD opioid use decreased over time postoperatively (β = -0.54, P < .001) with a median decrease of 90 mg morphine equivalents (MME) between the first and last PPP visit, resulting in 46% tapered off by PPP completion. Older age and duration in PPP were associated with lower MME, while mental health conditions, longer hospital stays and higher discharge opioid prescriptions were associated with higher MME. The average time to non-MOUD opioid taper was 1.79× longer in patients on buprenorphine (P = .026), 2.75× in males (P = .023), 4.66× with mental health conditions (P < .001), 2.37× with chronic pain (P = .031) and 3.51× if on preoperative non-MOUD opioids; however, higher initial MOUD level decreased time to taper (P = .001). CONCLUSIONS Postoperative opioid tapering utilizing a transitional pain service is possible in patients on MOUD.
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Affiliation(s)
- Olivia Liu
- Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - David Leon
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Ethan Gough
- Department of Biostatistics, Epidemiology and Data Management Core, Johns Hopkins University Bloomberg School of Public Health, Baltimore, MD, USA
| | - Traci Speed
- Department of Psychiatry and Behavioral Sciences, ohns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Marie Hanna
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Kellie Jaremko
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
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Quaye A, Tsafnat T, Richard JM, Stoddard H, Gagnon DJ. Post-operative pain control in patients on buprenorphine or methadone for opioid use disorder. J Opioid Manag 2024; 20:233-241. [PMID: 39017615 DOI: 10.5055/jom.0823] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/18/2024]
Abstract
OBJECTIVE This study aimed to determine whether there is a difference in pain scores and opioid consumption after elective surgery in patients maintained on methadone or buprenorphine for opioid use disorder (OUD). Additionally, we investigated the impact of continuing or discontinuing methadone or buprenorphine on post-operative pain outcomes. DESIGN A single-center retrospective cohort study. SETTING Tertiary care medical center. PATIENTS AND PARTICIPANTS Adults aged 18 years or older with OUD maintained on buprenorphine or methadone who underwent elective surgery between January 1, 2017, and January 1, 2021. INTERVENTIONS Patients were identified through electronic medical records, and demographic and clinical data were collected. MAIN OUTCOME MEASURES The primary outcome was opioid consumption at 24 hours post-operatively, measured in milligram morphine equivalents. The secondary outcome was opioid consumption and pain scores up to 72 hours post-operatively, assessed using a numeric rating scale. RESULTS This study included 366 patients (64 percent on buprenorphine and 36 percent on methadone). Opioid utilization significantly increased when buprenorphine was not administered post-operatively. Both groups exhibited comparable total opioid consumption during the post-operative period. In the buprenorphine cohort, pain scores differed significantly based on the receipt of medications for OUD post-operatively. CONCLUSIONS This study reinforces existing evidence supporting the continuation of medications for opioid use disorder, specifically buprenorphine and methadone, during the perioperative period. Dissemination of guideline recommendations is essential to ensure optimal post-operative pain management for this patient population.
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Affiliation(s)
- Aurora Quaye
- Department of Anesthesiology and Perioperative Medicine, Maine Medical Center, Portland; Division of Anesthesiology, Spectrum Healthcare Partners, South Portland, Maine; Tufts University School of Medicine, Boston, Massachusetts. ORCID: https://orcid.org/0000-0002-7573-2164
| | - Tal Tsafnat
- University of New England College of Osteopathic Medicine, Portland, Maine
| | - Janelle M Richard
- Department of Anesthesiology and Perioperative Medicine, Maine Medical Center, Portland, Maine. ORCID: https://orcid.org/0000-0002-2825-6134
| | - Henry Stoddard
- Center for Interdisciplinary Population & Health Research, Maine Health Institute for Research, Scarborough, Maine
| | - David J Gagnon
- Tufts University School of Medicine, Boston, Massachusetts; Department of Pharmacy, Maine Medical Center, Portland; MaineHealth Institute for Research, Scarborough, Maine
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Vu PD, Bansal V, Chitneni A, Robinson CL, Viswanath O, Urits I, Kaye AD, Nguyen A, Govindaraj R, Chen GH, Hasoon J. Buprenorphine for Chronic Pain Management: a Narrative Review. Curr Pain Headache Rep 2023; 27:811-820. [PMID: 37897592 DOI: 10.1007/s11916-023-01185-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/19/2023] [Indexed: 10/30/2023]
Abstract
PURPOSE OF REVIEW The aim of this review is to educate healthcare professionals regarding buprenorphine for the use of opioid use disorder (OUD) as well as for chronic pain management. This review provides physicians and practitioners with updated information regarding the distinct characteristics and intricacies of prescribing buprenorphine. RECENT FINDINGS Buprenorphine is approved by the US Food and Drug Administration (FDA) for acute pain, chronic pain, opioid use disorder (OUD), and opioid dependence. When compared to most other opioids, buprenorphine offers superior patient tolerability, an excellent half-life, and minimal respiratory depression. Buprenorphine does have notable side effects as well as pharmacokinetic properties that require special attention, especially if patients require future surgical interventions. Many physicians are not trained to initiate or manage patients on buprenorphine. However, buprenorphine offers a potentially safer alternative for medication management for patients who require chronic opioid therapy for pain or have OUD. This review provides updated information on buprenorphine for both chronic pain and OUD.
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Affiliation(s)
- Peter D Vu
- Department of Physical Medicine and Rehabilitation, The University of Texas Health Science Center at Houston, McGovern Medical School, Houston, TX, USA
| | - Vishal Bansal
- Department of Physical Medicine and Rehabilitation, The University of Texas Health Science Center at Houston, McGovern Medical School, Houston, TX, USA
| | - Ahish Chitneni
- Department of Rehabilitation and Regenerative Medicine, New York-Presbyterian Hospital - Columbia and Cornell, New York, NY, USA
| | - Christopher L Robinson
- Department of Anesthesiology, Critical Care, and Pain Medicine, Harvard Medical School, Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - Omar Viswanath
- Department of Anesthesiology, Louisiana State University Health Shreveport, Shreveport, LA, USA
| | - Ivan Urits
- Department of Anesthesiology, Louisiana State University Health Shreveport, Shreveport, LA, USA
| | - Alan D Kaye
- Department of Anesthesiology, Louisiana State University Health Shreveport, Shreveport, LA, USA
| | - Anvinh Nguyen
- Department of Anesthesiology, Baylor College of Medicine, Houston, TX, USA
| | - Ranganathan Govindaraj
- Department of Anesthesiology, Critical Care, and Pain Medicine, The University of Texas Health Science Center at Houston, McGovern Medical School, Houston, TX, USA
| | - Grant H Chen
- Department of Anesthesiology, Critical Care, and Pain Medicine, The University of Texas Health Science Center at Houston, McGovern Medical School, Houston, TX, USA
| | - Jamal Hasoon
- Department of Anesthesiology, Critical Care, and Pain Medicine, The University of Texas Health Science Center at Houston, McGovern Medical School, Houston, TX, USA.
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Quaye A, Mardmomen N, Mogren G, Ibrahim Y, Richard J, Zhang Y. Current State of Perioperative Buprenorphine Management-A National Provider Survey. J Addict Med 2023; 17:640-645. [PMID: 37934521 DOI: 10.1097/adm.0000000000001191] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/07/2023]
Abstract
OBJECTIVES Buprenorphine maintenance for opioid use disorder (OUD) can present potential challenges for acute postoperative pain management. Provider practice and consistency of buprenorphine management strategies within institutions are unknown. This study aims to identify how providers nationwide manage patients on buprenorphine when they present for elective surgery. METHODS A prospective survey of anesthesiologists was performed nationwide between November 2021 and March 2022. Survey respondents were selected from academic institutions identified using public databases and were also distributed to online social media platforms where members are required to verify medical licensure and hospital affiliation. Survey results were calculated and interpreted as the percentage rate of response. RESULTS Survey invitations were sent to 190 institutions and returned 54 responses (28% response rate). An additional 12 completed surveys were obtained from online social media distribution resulting in 66 responses. Only 36% of respondents reported an established protocol for perioperative management of buprenorphine at their institution. Regarding consistency of buprenorphine management within institutions, the majority of respondents endorsed buprenorphine continuation without dose reduction in procedures where minimal pain was anticipated. However, there was a large discrepancy in buprenorphine management for surgeries with moderate-severe pain. Perioperative dosing frequency of buprenorphine was also inconsistent. CONCLUSIONS The majority of institutions surveyed do not have an established protocol for perioperative buprenorphine management. In addition, there is provider variability in buprenorphine dosing for procedures with moderate-severe pain. This study highlights the need for dissemination of consensus guidelines for buprenorphine management.
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Affiliation(s)
- Aurora Quaye
- From the Spectrum Healthcare Partners, South Portland, ME (AQ); Department of Anesthesiology and Perioperative Medicine, Maine Medical Center, Portland, ME (AQ, YI, JR); Translational Pain Research Department, Massachusetts General Hospital, Boston, MA (NM, GM); and Department of Anesthesia, Critical Care, and Pain Medicine, Massachusetts General Hospital, Boston, MA (YZ)
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Haines AJ, Wood KC, Costello JL, Tawil T. Acute Pain Management for Patients Maintained on Sublingual Buprenorphine as Medication for Opioid Use Disorder. J Addict Med 2023; 17:662-669. [PMID: 37934527 DOI: 10.1097/adm.0000000000001205] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/29/2023]
Abstract
OBJECTIVE The aim of this study was to compare morphine milligram equivalent (MME) requirements for acute pain management between patients admitted for medical or surgical diagnoses with opioid use disorder (OUD) who receive >12 mg of sublingual buprenorphine daily compared with those who receive ≤12 mg/d. DESIGN This study was performed via retrospective chart review. SETTING This study evaluated patient encounters between January 2017 and November 2021 from a single-center community teaching hospital in Lancaster, PA. METHODS Patients were assessed according to daily dose of buprenorphine received while admitted (>12 mg/d vs ≤12 mg/d); patients who had buprenorphine held were included within the ≤12 mg/d study group. The primary outcome evaluated daily average MME requirements over the entirety of hospital length of stay. Key secondary outcomes were total MME requirements and daily average pain scores. SUBJECTS Key inclusion criteria were sublingual buprenorphine therapy for at least 1 month prior to admission, presence of an acute pain diagnosis during hospital stay, and history of OUD. RESULTS Seventy-eight (78) patients were included for analysis. Daily average MME requirements were similar between patients who received buprenorphine >12 mg/d and ≤12 mg/d (median, 7.5 vs 10.6; P = 0.350). Total MME and daily average pain scores were similar between study groups. CONCLUSIONS For OUD patients in need of acute pain management, the continuation of sublingual buprenorphine throughout hospitalization at a daily dose of >12 mg/d compared with ≤12 mg/d did not confer a significant difference in daily average MME requirements.
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Hauck TS, Ladha KS, Le Foll B, Wijeysundera DN, Kurdyak P. Postoperative buprenorphine continuation in stabilized buprenorphine patients: A population cohort study. Addiction 2023; 118:1953-1964. [PMID: 37332171 DOI: 10.1111/add.16223] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/04/2022] [Accepted: 04/05/2023] [Indexed: 06/20/2023]
Abstract
BACKGROUND AND AIMS Sudden discontinuation of buprenorphine in the treatment of opioid use disorder can increase the risk of subsequent relapse and overdose. Little is known about buprenorphine use in the perioperative period. The aim of this study was to determine the rate of buprenorphine continuation after hospital discharge following surgery and factors associated with continuation. DESIGN A population-based retrospective cohort study was conducted using administrative data from Ontario, Canada, between 2012 and 2018. The cohort included individuals on continuous buprenorphine prior to surgery. Logistic regression modeling was used to estimate the association of buprenorphine continuation with demographic, opioid agonist treatment, surgical and health service use factors. SETTING Administrative databases from Institute for Clinical Evaluative Sciences (ICES) were used, which capture the Ontario, Canada, population. The data sets describe physician billing, monitoring of controlled substances and hospital discharges. PARTICIPANTS Adults (≥ 18 years, n = 2176) had received a buprenorphine/naloxone product continuously for at least 60 days for the treatment of opioid use disorder and subsequently underwent a surgical procedure. MEASUREMENTS Continuation (versus discontinuation) of buprenorphine prescriptions in the 14 days after surgical discharge was recommended. Exposures included demographic, comorbidity, opioid agonist treatment, surgical and health service use characteristics. FINDINGS About 176 (8.1%) of the 2176 patients discontinued buprenorphine after surgery. Inpatient surgery (versus ambulatory) was associated with reduced odds of continuation, with an unadjusted odds ratio (OR) of 0.17 [95% confidence interval (CI) = 0.12-0.25] and an adjusted OR of 0.16 (95% CI = 0.11-0.23) after accounting for age, sex, rural residence, neighborhood income quintile, Charlson comorbidity index, psychiatric hospitalizations in the past 5 years and recent dispensed supply of buprenorphine (number needed to harm of 6.6). CONCLUSIONS In Ontario, Canada, from 2012 to 2018, most patients receiving continuous preoperative buprenorphine therapy continued buprenorphine use after surgery. Inpatient surgery was a strong predictor of discontinuation compared with ambulatory procedures.
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Affiliation(s)
- Tanya S Hauck
- Department of Psychiatry, Faculty of Medicine, University of Toronto, Toronto, ON, Canada
- Institute of Health Policy, Management and Evaluation, Faculty of Medicine, University of Toronto, Toronto, ON, Canada
- Centre for Addiction and Mental Health, Toronto, ON, Canada
- ICES Central, Toronto, ON, Canada
| | - Karim S Ladha
- Institute of Health Policy, Management and Evaluation, Faculty of Medicine, University of Toronto, Toronto, ON, Canada
- Department of Anesthesia, St Michael's Hospital, Toronto, ON, Canada
- Department of Anesthesiology and Pain Medicine, University of Toronto, Toronto, ON, Canada
- Li Ka Shing Knowledge Institute, St Michael's Hospital, Toronto, ON, Canada
| | - Bernard Le Foll
- Department of Psychiatry, Faculty of Medicine, University of Toronto, Toronto, ON, Canada
- Institute of Health Policy, Management and Evaluation, Faculty of Medicine, University of Toronto, Toronto, ON, Canada
- Centre for Addiction and Mental Health, Toronto, ON, Canada
- Department of Pharmacology and Toxicology, University of Toronto, Toronto, ON, Canada
- Department of Family and Community Medicine, University of Toronto, Toronto, ON, Canada
- Institute of Medical Sciences, University of Toronto, Toronto, ON, Canada
| | - Duminda N Wijeysundera
- Institute of Health Policy, Management and Evaluation, Faculty of Medicine, University of Toronto, Toronto, ON, Canada
- Department of Anesthesia, St Michael's Hospital, Toronto, ON, Canada
- Department of Anesthesiology and Pain Medicine, University of Toronto, Toronto, ON, Canada
- Li Ka Shing Knowledge Institute, St Michael's Hospital, Toronto, ON, Canada
| | - Paul Kurdyak
- Department of Psychiatry, Faculty of Medicine, University of Toronto, Toronto, ON, Canada
- Institute of Health Policy, Management and Evaluation, Faculty of Medicine, University of Toronto, Toronto, ON, Canada
- Centre for Addiction and Mental Health, Toronto, ON, Canada
- ICES Central, Toronto, ON, Canada
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Borelli C, Gaub M. Letter: What Neurosurgeons Need to Know About Perioperative Buprenorphine for Opioid Use Disorder. Neurosurgery 2023; 93:e71-e72. [PMID: 37294095 DOI: 10.1227/neu.0000000000002577] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2023] [Accepted: 05/03/2023] [Indexed: 06/10/2023] Open
Affiliation(s)
- Cara Borelli
- Department of Psychiatry, Addiction Institute of Mount Sinai West and Mount Sinai Morningside, Mount Sinai Morningside/West, New York , New York , USA
| | - Michael Gaub
- Department of Neurosurgery, The University of Texas Health Science Center San Antonio, San Antonio , Texas , USA
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Barreveld AM, Mendelson A, Deiling B, Armstrong CA, Viscusi ER, Kohan LR. Caring for Our Patients With Opioid Use Disorder in the Perioperative Period: A Guide for the Anesthesiologist. Anesth Analg 2023; 137:488-507. [PMID: 37590794 DOI: 10.1213/ane.0000000000006280] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/19/2023]
Abstract
Opioid use disorder (OUD) is a rising public health crisis, impacting millions of individuals and families worldwide. Anesthesiologists can play a key role in improving morbidity and mortality around the time of surgery by informing perioperative teams and guiding evidence-based care and access to life-saving treatment for patients with active OUD or in recovery. This article serves as an educational resource for the anesthesiologist caring for patients with OUD and is the second in a series of articles published in Anesthesia & Analgesia on the anesthetic and analgesic management of patients with substance use disorders. The article is divided into 4 sections: (1) background to OUD, treatment principles, and the anesthesiologist; (2) perioperative considerations for patients prescribed medications for OUD (MOUD); (3) perioperative considerations for patients with active, untreated OUD; and (4) nonopioid and nonpharmacologic principles of multimodal perioperative pain management for patients with untreated, active OUD, or in recovery. The article concludes with a stepwise approach for the anesthesiologist to support OUD treatment and recovery. The anesthesiologist is an important leader of the perioperative team to promote these suggested best practices and help save lives.
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Affiliation(s)
- Antje M Barreveld
- From the Department of Anesthesiology, Tufts University School of Medicine, Newton-Wellesley Hospital, Newton, Massachusetts
| | - Andrew Mendelson
- Department of Anesthesiology, University of Virginia School of Medicine, University of Virginia Hospital, Charlottesville, Virginia
| | - Brittany Deiling
- Department of Anesthesiology, University of Virginia School of Medicine, University of Virginia Hospital, Charlottesville, Virginia
| | - Catharina A Armstrong
- Department of Medicine, Tufts University School of Medicine, Newton-Wellesley Hospital, Newton, Massachusetts
| | - Eugene R Viscusi
- Department of Anesthesiology, Sidney Kimmel Medical College of Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Lynn R Kohan
- Department of Anesthesiology, University of Virginia School of Medicine, University of Virginia Hospital, Charlottesville, Virginia
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Hathaway DB, Bhat JA, Twark C, Rodriguez C, Suzuki J. Patients' experiences with continuation or discontinuation of buprenorphine before painful procedures: A brief report. Am J Addict 2023; 32:410-414. [PMID: 36850041 DOI: 10.1111/ajad.13396] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2022] [Revised: 02/09/2023] [Accepted: 02/10/2023] [Indexed: 03/01/2023] Open
Abstract
BACKGROUND AND OBJECTIVES Patients with opioid use disorder may be asked by their clinicians to discontinue maintenance buprenorphine treatment before surgical operations due to concerns that buprenorphine will interfere with acute pain management. However, discontinuation of buprenorphine may not be well tolerated or safe for all patients. We, therefore, administered a survey to better understand the experiences of patients on buprenorphine treatment who had previously undergone painful procedures and had their buprenorphine maintenance treatment either continued or discontinued before the procedure. METHODS After this study received institutional review board approval, patients were invited to participate if they were being prescribed sublingual buprenorphine for treatment of opioid use disorder and had also previously undergone a painful procedure requiring treatment with full agonist opioids. Patients who were eligible and agreed to participate (n = 32) then completed a survey of basic demographics; medical, psychiatric, and substance use histories; and their experience and satisfaction with the treatment of pain and substance use in the perioperative period, including whether buprenorphine was continued or discontinued before their procedure. RESULTS Compared with patients whose home dose of buprenorphine was continued (n = 15), patients whose buprenorphine was discontinued preoperatively (n = 17) reported less satisfaction with pain management and were more likely to be prescribed full agonist opioids upon discharge. DISCUSSION AND CONCLUSIONS Consistent with prior studies, these survey findings suggest that discontinuation of buprenorphine before painful surgeries may be associated with poorer clinical outcomes. SCIENTIFIC SIGNIFICANCE This survey study adds patients' perspective to a growing body of scientific literature suggesting that discontinuation of maintenance buprenorphine treatment before painful procedures may decrease patient satisfaction and increase clinical risk.
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Affiliation(s)
- David B Hathaway
- Department of Psychiatry, Brigham and Women's Hospital, Boston, Massachusetts, USA
- Department of Psychiatry, Harvard Medical School, Boston, Massachusetts, USA
| | - Jasra-Ali Bhat
- Department of Psychiatry, Brigham and Women's Hospital, Boston, Massachusetts, USA
- Department of Psychiatry, Harvard Medical School, Boston, Massachusetts, USA
| | - Claire Twark
- Department of Psychiatry, Brigham and Women's Hospital, Boston, Massachusetts, USA
- Department of Psychiatry, Harvard Medical School, Boston, Massachusetts, USA
| | - Claudia Rodriguez
- Department of Psychiatry, Brigham and Women's Hospital, Boston, Massachusetts, USA
- Department of Psychiatry, Harvard Medical School, Boston, Massachusetts, USA
| | - Joji Suzuki
- Department of Psychiatry, Brigham and Women's Hospital, Boston, Massachusetts, USA
- Department of Psychiatry, Harvard Medical School, Boston, Massachusetts, USA
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Arnet I, Dürsteler KM, Jaiteh C, Grossmann F, Hersberger KE. Rescue Analgesia for Opioid-Dependent Individuals on Opioid Agonist Treatment during Hospitalization: Adherence to Guideline Treatment. Eur Addict Res 2023; 29:253-263. [PMID: 37302389 PMCID: PMC10614254 DOI: 10.1159/000530266] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/10/2022] [Accepted: 03/16/2023] [Indexed: 06/13/2023]
Abstract
INTRODUCTION Opioid agonist treatment (OAT) is the first-line treatment for opioid use disorder (OUD). Simultaneously, opioids are essential medicines in acute pain management. The literature is scarce on acute pain management in individuals with OUD, and guidelines are controversial for patients on OAT. We aimed at analyzing rescue analgesia in opioid-dependent individuals on OAT during hospitalization in the University Hospital Basel, Switzerland. METHODS Patient hospital records were extracted from the database over 6 months (Jan-Jun) in 2015 and 2018. Of the 3,216 extracted patient records, we identified 255 cases on OAT with full datasets. Rescue analgesia was defined according to established principles of acute pain management, e.g., i) the analgesic agent is identical to the OAT medication, and ii) the opioid agent is dosed above 1/6th morphine equivalent dose of the OAT medication. RESULTS The patients were on average 51.3 ± 10.5 years old (range: 22-79 years), of which 64% were men. The most frequent OAT agents were methadone and morphine (34.9% and 34.5%). Rescue analgesia was not documented in 14 cases. Guideline-concordant rescue analgesia was observed in 186 cases (72.9%) and consisted mostly of NSAIDs, including paracetamol (80 cases), and identical agents such as the OAT opioid (70 cases). Guideline-divergent rescue analgesia was observed in 69 (27.1%) cases, predominantly due to an underdosed opioid agent (32 cases), another agent other than the OAT (18 cases), or contraindicated agents (10 cases). DISCUSSION Our analysis suggests that rescue analgesia in hospitalized OAT patients was predominantly concordant with guidelines, while divergent prescriptions seemed to follow common principles of pain medicine. Clear guidelines are needed to appropriately treat acute pain in hospitalized OAT patients.
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Affiliation(s)
- Isabelle Arnet
- Department of Pharmaceutical Sciences, Pharmaceutical Care Research Group, University of Basel, Basel, Switzerland
| | - Kenneth M. Dürsteler
- University Psychiatric Clinics Basel, Basel, Switzerland
- Department for Psychiatry, Psychotherapy and Psychosomatics, Psychiatric Hospital, University of Zurich, Zurich, Switzerland
| | - Christine Jaiteh
- Department of Acute Medicine, University Hospital Basel, Basel, Switzerland
| | - Florian Grossmann
- Department of Acute Medicine, University Hospital Basel, Basel, Switzerland
| | - Kurt E. Hersberger
- Department of Pharmaceutical Sciences, Pharmaceutical Care Research Group, University of Basel, Basel, Switzerland
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Culshaw JR, Philpott CD, Garber Bradshaw P, Brizzi MB, Goodman MD, Makley AT, Reinstatler KM, Droege ME. Acute Pain Management in Traumatically Injured Patients With Outpatient Buprenorphine Therapy. J Surg Res 2023; 289:27-34. [PMID: 37079963 DOI: 10.1016/j.jss.2023.03.021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2022] [Revised: 03/09/2023] [Accepted: 03/17/2023] [Indexed: 04/22/2023]
Abstract
INTRODUCTION Acute pain management is challenging in trauma patients undergoing outpatient buprenorphine therapy at the time of injury due to the high binding affinity of this partial agonist. The purpose of this study was to evaluate acute pain management in admitted trauma patients with discontinued versus continued outpatient buprenorphine therapy. MATERIALS AND METHODS This retrospective study included adult trauma patients admitted to a level-1 trauma center between January 2017 and August 2020 who were receiving buprenorphine prior to admission. Groups were defined as buprenorphine discontinued (BD) or continued (BC) during hospitalization. The primary outcome compared median daily morphine milligram equivalents between groups. Secondary outcomes utilized patient-reported numeric rating scale (NRS) scores to compare incidences of no pain (NRS 0), mild (NRS 1-3), moderate (NRS 4-6), and severe (NRS 7-10) pain. RESULTS A total of 57 patients were included (BD 37 [64.9%] and BC 20 [35.1%]). The median (interquartile range) outpatient daily buprenorphine dose was similar between groups (8 [8-16] mg versus 16 [8-16], P = 0.25). Median daily morphine milligram equivalents was significantly higher during admission in the BD group (103.7 [80.7-166] versus 67 [30.8-97.4], P = 0.002). Incidence of no pain (7.1% versus 5.7%, P = 0.283), mild (5.5% versus 4.3%, P = 0.295), moderate (20.2%, 19.8%, P = 0.855), or severe (67.2% versus 70.2%, P = 0.185) pain was similar between BD and BC groups, respectively. CONCLUSIONS Continuation of outpatient buprenorphine therapy in acute trauma patients is associated with decreased daily opioid requirements and similar analgesic efficacy compared to patients with BD. Based on our findings, trauma patients receiving outpatient buprenorphine and not requiring ventilator support may benefit from buprenorphine continuation within 48 h of initial presentation.
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Affiliation(s)
| | - Carolyn D Philpott
- UC Health - University of Cincinnati Medical Center, Cincinnati, Ohio; University of Cincinnati James L. Winkle College of Pharmacy, Cincinnati, Ohio
| | - Paige Garber Bradshaw
- UC Health - University of Cincinnati Medical Center, Cincinnati, Ohio; University of Cincinnati James L. Winkle College of Pharmacy, Cincinnati, Ohio
| | | | - Michael D Goodman
- UC Health - University of Cincinnati Medical Center, Cincinnati, Ohio; Department of Surgery, University of Cincinnati, Cincinnati, Ohio
| | - Amy Teres Makley
- UC Health - University of Cincinnati Medical Center, Cincinnati, Ohio; Department of Surgery, University of Cincinnati, Cincinnati, Ohio
| | - Kristina Marie Reinstatler
- UC Health - University of Cincinnati Medical Center, Cincinnati, Ohio; University of Cincinnati James L. Winkle College of Pharmacy, Cincinnati, Ohio; University of Cincinnati College of Nursing, Cincinnati, Ohio
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Neale KJ, Weimer MB, Davis MP, Jones KF, Kullgren JG, Kale SS, Childers J, Broglio K, Merlin JS, Peck S, Francis SY, Bango J, Jones CA, Sager Z, Ho JJ. Top Ten Tips Palliative Care Clinicians Should Know About Buprenorphine. J Palliat Med 2023; 26:120-130. [PMID: 36067137 DOI: 10.1089/jpm.2022.0399] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023] Open
Abstract
Pain management in palliative care (PC) is becoming more complex as patients survive longer with life-limiting illnesses and population-wide trends involving opioid misuse become more common in serious illness. Buprenorphine, a generally safe partial mu-opioid receptor agonist, has been shown to be effective for both pain management and opioid use disorder. It is critical that PC clinicians become comfortable with indications for its use, strategies for initiation while understanding risks and benefits. This article, written by a team of PC and addiction-trained specialists, including physicians, nurse practitioners, social workers, and a pharmacist, offers 10 tips to demystify buprenorphine use in serious illness.
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Affiliation(s)
- Kyle J Neale
- The Lois U and Harry R Horvitz Palliative Medicine Program, Department of Palliative Medicine and Supportive Care, Taussig Cancer Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Melissa B Weimer
- Program in Addiction Medicine, Department of Medicine, Yale School of Medicine, New Haven, Connecticut, USA
| | - Mellar P Davis
- Department of Palliative Care, Geisinger Medical Center, Danville, Pennsylvania, USA
| | | | - Justin G Kullgren
- Palliative Medicine Clinical Pharmacy, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Sachin S Kale
- Division of Palliative Medicine, Department of Medicine, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Julie Childers
- Section of Palliative Care and Medical Ethics, Division of General Internal Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Kathleen Broglio
- Section of Palliative Medicine, Geisel School of Medicine at Dartmouth, Collaboratory for Implementation Sciences at Dartmouth, Lebanon, New Hampshire, USA
| | - Jessica S Merlin
- Section of Palliative Care and Medical Ethics and Palliative Research Center, Division of General Internal Medicine, Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Sarah Peck
- Division of Palliative Medicine, Emory University Healthcare Midtown, Atlanta, Georgia, USA
| | - Sheria Y Francis
- Collaborative Care Management, University of Pittsburgh Medical Center Presbyterian Shadyside, Pittsburgh, Pennsylvania, USA
| | | | - Christopher A Jones
- Department of Medicine, Duke University School of Medicine, Durham, North Carolina, USA
| | - Zachary Sager
- Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute and Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - J Janet Ho
- Division of Palliative Medicine, University of California San Francisco, San Francisco, California, USA
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14
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Olney WJ, Johnson EG, Potts C, Murphy JT, Oyler DR. Continuing Chronic Buprenorphine Perioperatively is Associated With Reduced Postoperative Opioid Use. J Surg Res 2023; 281:63-69. [PMID: 36116209 DOI: 10.1016/j.jss.2022.08.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2021] [Revised: 06/14/2022] [Accepted: 08/11/2022] [Indexed: 01/31/2023]
Abstract
INTRODUCTION Buprenorphine is a frequently used medication for opioid use disorder and misunderstanding buprenorphine's unique pharmacology has historically complicated perioperative analgesia. The purpose of this study was to evaluate the association of perioperative buprenorphine continuation in patients with substance use disorder on perioperative opioid use. MATERIALS AND METHODS This was a single-center retrospective study at a level 1 trauma academic medical center. Adult patients using outpatient buprenorphine for medication for opioid use disorder admitted with an operating room booking were included. Patients were grouped (continuation, withheld) retrospectively based upon the decision to continue or omit buprenorphine therapy while admitted. The primary outcome of the study was any use of full mu-opioid agonists during days 1-7 of admission. Secondary outcomes included length of stay and average pain scores during days 1-7 of admission. RESULTS 43.4% of patients in the continuation cohort used no full mu-opioid agonists during days 1-7 compared to 3.1% of patients in the withheld cohort (P < 0.001). No significant difference in median length of stay was noted (4.7 d [2.8-6.6] versus 6.1 d [4.0-8.2], P = 0.36). There was no statistical difference in average pain scores on postoperative days 1 (5.2 versus 6.9, P = 0.82) and 7 (0 versus 0, P = 0.41). CONCLUSIONS Perioperative continuation of buprenorphine is associated with reduced use of alternative full mu-opioid agents while admitted without impacting pain scores.
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Affiliation(s)
- William J Olney
- Department of Pharmacy, University of Kentucky Medical Center, Lexington, Kentucky.
| | - Eric G Johnson
- Department of Pharmacy, University of Kentucky Medical Center, Lexington, Kentucky; University of Kentucky College of Pharmacy, Lexington, Kentucky
| | - Cassidy Potts
- University of Kentucky College of Pharmacy, Lexington, Kentucky
| | - J Thomas Murphy
- Department of Anesthesiology, University of Kentucky Medical Center, Lexington, Kentucky; University of Kentucky College of Medicine, Lexington, Kentucky
| | - Douglas R Oyler
- University of Kentucky College of Pharmacy, Lexington, Kentucky
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15
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Perioperative Management of Extended-release Buprenorphine. J Addict Med 2023; 17:e67-e71. [PMID: 35862898 DOI: 10.1097/adm.0000000000001024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Perioperative management of buprenorphine is increasingly characterized by continuation of buprenorphine throughout the perioperative period while coadministering full agonist opioids for analgesia. Although this "simultaneous strategy" is commonly used for the shorter-acting sublingual buprenorphine formulations, there is little to guide management of the extended-release formulations of buprenorphine. Here we report the perioperative experience of an individual maintained on extended-release buprenorphine who successfully underwent major surgeries utilizing a strategy of performing the surgeries at the time of the next scheduled dose.
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16
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Hyland SJ, Wetshtein AM, Grable SJ, Jackson MP. Acute Pain Management Pearls: A Focused Review for the Hospital Clinician. Healthcare (Basel) 2022; 11:healthcare11010034. [PMID: 36611494 PMCID: PMC9818465 DOI: 10.3390/healthcare11010034] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2022] [Revised: 12/15/2022] [Accepted: 12/19/2022] [Indexed: 12/24/2022] Open
Abstract
Acute pain management is a challenging area encountered by inpatient clinicians every day. While patient care is increasingly complex and costly in this realm, the availability of applicable specialists is waning. This narrative review seeks to support diverse hospital-based healthcare providers in refining and updating their acute pain management knowledge base through clinical pearls and point-of-care resources. Practical guidance is provided for the design and adjustment of inpatient multimodal analgesic regimens, including conventional and burgeoning non-opioid and opioid therapies. The importance of customized care plans for patients with preexisting opioid tolerance, chronic pain, or opioid use disorder is emphasized, and current recommendations for inpatient management of associated chronic therapies are discussed. References to best available guidelines and literature are offered for further exploration. Improved clinician attention and more developed skill sets related to acute pain management could significantly benefit hospitalized patient outcomes and healthcare resource utilization.
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Affiliation(s)
- Sara J. Hyland
- Department of Pharmacy, OhioHealth Grant Medical Center, Columbus, OH 43215, USA
- Correspondence:
| | - Andrea M. Wetshtein
- Department of Pharmacy, Cleveland Clinic Fairview Hospital, Cleveland, OH 44111, USA
| | - Samantha J. Grable
- Hospice and Palliative Medicine, OhioHealth Grant Medical Center, Columbus, OH 43215, USA
| | - Michelle P. Jackson
- Hospice and Palliative Medicine, OhioHealth Grant Medical Center, Columbus, OH 43215, USA
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17
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Clifton D, Ivey N, Poley S, O'Regan A, Raman SR, Frascino N, Hamilton S, Setji N. Implementation of a comprehensive hospitalist-led initiative to improve care for patients with opioid use disorder. J Hosp Med 2022; 17:427-436. [PMID: 35535562 PMCID: PMC9321616 DOI: 10.1002/jhm.12837] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/07/2021] [Revised: 03/30/2022] [Accepted: 04/15/2022] [Indexed: 01/26/2023]
Abstract
BACKGROUND As opioid-related hospitalizations rise, hospitals must be prepared to evaluate and treat patients with opioid use disorder (OUD). We implemented a hospitalist-led program, Project Caring for patients with Opioid Misuse through Evidence-based Treatment (COMET) to address gaps in care for hospitalized patients with OUD. OBJECTIVE Implement evidence-based treatment for inpatients with OUD and refer to postdischarge care. DESIGN, SETTING, AND PARTICIPANTS Project COMET launched in July 2019 at Duke University Hospital (DUH), an academic medical center in Durham, NC. INTERVENTION, MAIN OUTCOMES, AND MEASURES We engaged key stakeholders, performed a needs assessment, and secured health system funding. We developed protocols to standardize OUD treatment and employed a social worker to facilitate postdischarge care. Electronic health records were utilized for data analysis. RESULTS COMET evaluated 512 patients for OUD during their index hospitalization from July 1, 2019 through June 30, 2021. Seventy-one percent of patients received medication for OUD (MOUD) during admission. Of those who received buprenorphine during admission, 64% received a discharge prescription. Of those who received methadone during admission, 83% of eligible patients were connected to a methadone clinic. Among all patients at DUH with OUD, MOUD use during hospitalization and at discharge increased in the post-COMET period compared to the pre-COMET period (p < .001 for both). CONCLUSION Our program is one of the first to demonstrate successful implementation of a hospitalist-led, comprehensive approach to caring for hospitalized patients with OUD and can serve as an example to other institutions seeking to implement life-saving, evidence-based treatment in this population.
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Affiliation(s)
- Dana Clifton
- Department of MedicineDivision of General Internal Medicine, Duke University School of MedicineDurhamNorth CarolinaUSA
- Department of PediatricsDuke University School of MedicineDurhamNorth CarolinaUSA
| | - Noel Ivey
- Department of MedicineDivision of General Internal Medicine, Duke University School of MedicineDurhamNorth CarolinaUSA
| | - Stephanie Poley
- Duke Clinical Research Institute, Duke University School of MedicineDurhamNorth CarolinaUSA
| | - Amy O'Regan
- Department of Population Health SciencesDuke University School of MedicineDurhamNorth CarolinaUSA
| | - Sudha R. Raman
- Department of Population Health SciencesDuke University School of MedicineDurhamNorth CarolinaUSA
| | - Nicole Frascino
- Department of Population Health SciencesDuke University School of MedicineDurhamNorth CarolinaUSA
| | - Shavone Hamilton
- Clinical Social Work, Duke University HospitalDurhamNorth CarolinaUSA
| | - Noppon Setji
- Department of MedicineDivision of General Internal Medicine, Duke University School of MedicineDurhamNorth CarolinaUSA
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18
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Prabhakar NK, Chadwick AL, Nwaneshiudu C, Aggarwal A, Salmasi V, Lii TR, Hah JM. Management of Postoperative Pain in Patients Following Spine Surgery: A Narrative Review. Int J Gen Med 2022; 15:4535-4549. [PMID: 35528286 PMCID: PMC9075013 DOI: 10.2147/ijgm.s292698] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2022] [Accepted: 04/20/2022] [Indexed: 11/23/2022] Open
Abstract
Perioperative pain management is a unique challenge in patients undergoing spine surgery due to the increased incidence of both pre-existing chronic pain conditions and chronic postsurgical pain. Peri-operative planning and counseling in spine surgery should involve an interdisciplinary approach that includes consideration of patient-level risk factors, as well as pharmacologic and non-pharmacologic pain management techniques. Consideration of psychological factors and patient focused education as an adjunct to these measures is paramount in developing a personalized perioperative pain management plan. Understanding the currently available body of knowledge surrounding perioperative opioid management, management of opioid use disorder, regional/neuraxial anesthetic techniques, ketamine/lidocaine infusions, non-opioid oral analgesics, and behavioral interventions can be useful in developing a comprehensive, multi-modal treatment plan among patients undergoing spine surgery. Although many of these techniques have proved efficacious in the immediate postoperative period, long-term follow-up is needed to define the impact of such approaches on persistent pain and opioid use. Future techniques involving the use of precision medicine may help identify phenotypic and physiologic characteristics that can identify patients that are most at risk of developing persistent postoperative pain after spine surgery.
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Affiliation(s)
- Nitin K Prabhakar
- Department of Orthopaedic Surgery, Stanford University, Stanford, CA, USA
| | - Andrea L Chadwick
- Department of Anesthesiology, Pain, and Perioperative Medicine, University of Kansas School of Medicine, Kansas City, KS, USA
| | - Chinwe Nwaneshiudu
- Department of Anesthesiology, Perioperative and Pain Management, Mount Sinai Hospital, Icahn School of Medicine, New York, NY, USA
| | - Anuj Aggarwal
- Department of Anesthesiology, Perioperative, and Pain Medicine, Stanford University, Stanford, CA, USA
| | - Vafi Salmasi
- Department of Anesthesiology, Perioperative, and Pain Medicine, Stanford University, Stanford, CA, USA
| | - Theresa R Lii
- Department of Anesthesiology, Perioperative, and Pain Medicine, Stanford University, Stanford, CA, USA
| | - Jennifer M Hah
- Department of Anesthesiology, Perioperative, and Pain Medicine, Stanford University, Stanford, CA, USA
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19
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Murnion BP, Demirkol A. Opioid use disorder in anaesthesia and intensive care: Prevention, diagnosis and management. Anaesth Intensive Care 2022; 50:95-107. [PMID: 35189716 DOI: 10.1177/0310057x211066929] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Opioid misuse is common, as is opioid agonist treatment of opioid dependence. Almost 3% of Australians and over 3.5% of those living in New Zealand report misuse of analgesics. Over 50,000 Australians receive opioid agonist treatment with methadone or buprenorphine for management of severe opioid use disorder.The perioperative period is an opportunity to identify pre-existing opioid misuse, and to introduce interventions to reduce the risk of development of opioid use disorder. Challenges of acute perioperative pain management or intensive care management of patients receiving opioid agonist treatment include opioid tolerance and ongoing prescribing of methadone or buprenorphine. There has been some ambiguity about the optimal perioperative management of buprenorphine, a partial agonist at the mu receptor.In this article, a framework to identify emerging opioid misuse problems, identify risk of overdose and to manage the opioid-dependent patient on opioid agonist treatment perioperatively or in the intensive care unit is provided. Diagnostic criteria and risk stratification criteria are presented. Management strategies include trauma-informed care, care planning and care coordination with community practitioners and opioid agonist treatment providers. Continuing methadone or buprenorphine perioperatively with additional opioid and non-opioid analgesia is generally recommended. Increased opioid agonist treatment doses may be required on discharge. An algorithm for decisions about opioid agonist treatment management in the intensive care unit based on the risks of opioid withdrawal and toxicity is considered. Strategies for managing the opioid-dependent patient who is not in treatment are also discussed.
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Affiliation(s)
- Bridin P Murnion
- Drug and Alcohol Services, Western Sydney Local Health District, Sydney, Australia.,Faculty of Medicine and Health, University of Sydney, Sydney, Australia
| | - Apo Demirkol
- Drug and Alcohol Services, South Eastern Sydney Local Health District, Sydney, Australia.,School of Public Health and Community Medicine, University of New South Wales, Sydney, Australia
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20
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Chung BA, Sweitzer B. Optimization of patients with chronic pain and previous opioid use disorders. Int Anesthesiol Clin 2022; 60:48-55. [PMID: 34897221 DOI: 10.1097/aia.0000000000000349] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Affiliation(s)
- Brian A Chung
- Department of Anesthesiology, Northwestern Memorial Hospital, Chicago, Illinois
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21
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Hickey T, Abelleira A, Acampora G, Becker WC, Falker CG, Nazario M, Weimer MB. Perioperative Buprenorphine Management: A Multidisciplinary Approach. Med Clin North Am 2022; 106:169-185. [PMID: 34823729 DOI: 10.1016/j.mcna.2021.09.001] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Buprenorphine formulations (including buprenorphine/naloxone) are effective treatments of pain and opioid use disorder (OUD). Historically, perioperative management of patients prescribed buprenorphine involved abstinence from buprenorphine sufficient to allow for unrestricted mu-opioid receptor availability to full agonist opioid (FAO) treatment. Evidence is mounting that a multimodal analgesic strategy, including simultaneous administration of buprenorphine and FAO, nonopioid adjuncts such as acetaminophen and nonsteroidal anti-inflammatory drugs, and regional anesthesia, is a safe and effective perioperative strategy for the patient prescribed long-term buprenorphine treatment of OUD. This strategy will likely simplify management and more seamlessly provide continuous buprenorphine treatment of OUD after hospital discharge.
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MESH Headings
- Acetaminophen/administration & dosage
- Acetaminophen/therapeutic use
- Aged
- Analgesics, Non-Narcotic/administration & dosage
- Analgesics, Non-Narcotic/therapeutic use
- Analgesics, Opioid/administration & dosage
- Analgesics, Opioid/pharmacology
- Analgesics, Opioid/therapeutic use
- Anti-Inflammatory Agents, Non-Steroidal/administration & dosage
- Anti-Inflammatory Agents, Non-Steroidal/therapeutic use
- Arthroplasty, Replacement, Hip/adverse effects
- Arthroplasty, Replacement, Hip/methods
- Buprenorphine/administration & dosage
- Buprenorphine/pharmacology
- Buprenorphine/therapeutic use
- Combined Modality Therapy/methods
- Drug Compounding/methods
- Female
- Humans
- Interdisciplinary Communication
- Male
- Opiate Substitution Treatment/methods
- Opioid-Related Disorders/drug therapy
- Pain/drug therapy
- Pain Management/methods
- Pain, Postoperative/prevention & control
- Perioperative Care/methods
- Receptors, Opioid, mu/drug effects
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Affiliation(s)
- Thomas Hickey
- VA Connecticut Healthcare System, 950 Campbell Avenue, West Haven, CT 06516, USA; Department of Anesthesiology, Yale School of Medicine, 950 Campbell Avenue, West Haven, CT 06516, USA.
| | - Audrey Abelleira
- VA Connecticut Healthcare System, 950 Campbell Avenue, West Haven, CT 06516, USA
| | - Gregory Acampora
- MGH/Harvard Center for Addiction Medicine, Pain Management Center at MGH, Harvard Medical School, Massachusetts General Hospital, 55 Fruit Street, Boston, MA 02114, USA
| | - William C Becker
- Pain Research, Informatics, Multimorbidities and Education Center, VA Connecticut Healthcare System; Program in Addiction Medicine, Yale School of Medicine
| | - Caroline G Falker
- VA Connecticut Healthcare System, 950 Campbell Avenue, West Haven, CT 06516, USA
| | - Mitchell Nazario
- National PBM Clinical Program Manager, VHA Pharmacy Benefits Management (12PBM), 1st Avenue - 1 Block North of Cermak (Building 37), Hines, IL 60141, USA
| | - Melissa B Weimer
- Program in Addiction Medicine, Yale School of Medicine; Yale School of Public Health
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22
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Merlin JS, Khodyakov D, Arnold R, Bulls HW, Dao E, Kapo J, King C, Meier D, Paice J, Ritchie C, Liebschutz JM. Expert Panel Consensus on Management of Advanced Cancer-Related Pain in Individuals With Opioid Use Disorder. JAMA Netw Open 2021; 4:e2139968. [PMID: 34962565 DOI: 10.1001/jamanetworkopen.2021.39968] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
IMPORTANCE Opioid use disorder (OUD) is an important comorbidity in individuals with advanced cancer, in whom pain is common. Full-agonist opioid medications are the cornerstone of cancer pain management, but the existing literature does not address how to manage cancer pain in patients with OUD. OBJECTIVE To conduct an expert panel to develop consensus on the appropriateness of management of cancer pain in individuals with co-occurring advanced cancer and OUD. EVIDENCE REVIEW A 3-round modified Delphi process was completed from August to October 2020 with 2 cases: patient with advanced cancer, pain, and OUD treated with buprenorphine-naloxone or methadone. Participants rated management strategies in round 1, discussed results in round 2, and provided final responses in round 3. ExpertLens, an online approach to conducting modified Delphi panels, was used. Participants were experts in palliative care, addiction, or both, recruited by email from palliative care and addiction-focused professional groups, lists from prior studies, and snowball sampling. Data analysis was performed from November 2020 to July 2021. FINDINGS Of 120 experts (median age, 40-49 years), most were White (78 participants [94%]), female (74 participants [62%]), and held MD or DO degrees (115 participants [96%]); 84 (70%) participated in all rounds. For a patient with OUD taking buprenorphine-naloxone, it was deemed appropriate to continue buprenorphine-naloxone with thrice-daily dosing. Continuing buprenorphine-naloxone and adding a full-agonist opioid was deemed to be appropriate for patients with a prognosis of weeks to months and of uncertain appropriateness for patients with a prognosis of months to years. For a patient with OUD taking methadone dispensed at a methadone clinic, it was deemed appropriate to take over prescribing and dose twice or thrice daily. Continuing methadone daily while adding another full-agonist opioid was deemed appropriate for patients with a prognosis of weeks to months and of uncertain appropriateness for those with a prognosis of months to years. CONCLUSIONS AND RELEVANCE The findings of this qualitative study provide urgently needed, consensus-based guidance for clinicians and highlight critical research and policy gaps needed to facilitate implementation.
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Affiliation(s)
- Jessica S Merlin
- CHAllenges in Managing and Preventing Pain Clinical Research Center, University of Pittsburgh, Pittsburgh, Pennsylvania
- Division of General Internal Medicine, Center for Research on Health Care, University of Pittsburgh, Pittsburgh, Pennsylvania
- Division of General Internal Medicine, Section of Palliative Care and Medical Ethics, University of Pittsburgh, Pittsburgh, Pennsylvania
| | | | - Robert Arnold
- Division of General Internal Medicine, Section of Palliative Care and Medical Ethics, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Hailey W Bulls
- CHAllenges in Managing and Preventing Pain Clinical Research Center, University of Pittsburgh, Pittsburgh, Pennsylvania
- Division of General Internal Medicine, Center for Research on Health Care, University of Pittsburgh, Pittsburgh, Pennsylvania
- Division of General Internal Medicine, Section of Palliative Care and Medical Ethics, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Emily Dao
- RAND Corporation, Santa Monica, California
| | - Jennifer Kapo
- Palliative Medicine, Yale University School of Medicine, New Haven, Connecticut
| | - Caroline King
- Department of Biomedical Engineering, School of Medicine, Oregon Health & Science University, Portland
| | - Diane Meier
- Department of Geriatrics and Palliative Medicine, Center to Advance Palliative Care, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Judith Paice
- Feinberg School of Medicine, Division Hematology-Oncology, Northwestern University, Chicago, Illinois
| | - Christine Ritchie
- Division of Palliative Care and Geriatric Medicine, Massachusetts General Hospital, Boston
| | - Jane M Liebschutz
- Division of General Internal Medicine, Center for Research on Health Care, University of Pittsburgh, Pittsburgh, Pennsylvania
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23
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Mayfield K, White L, Nolan T, Conner X, Dittmer B, Abi-Fares C, Mitchell A. Management of surgical patients on opioid replacement therapy: An audit of current practice. J Perioper Pract 2021; 33:107-115. [PMID: 34787035 DOI: 10.1177/17504589211045233] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Patients on opioid replacement therapy hospitalised with acute pain represent a clinical challenge and have poorer perioperative outcomes. There is limited evidence relating to acute pain management of this complex cohort. The primary objectives of this retrospective audit was to establish the number of patients who are admitted on opioid replacement therapy with an acute pain condition under surgical services and evaluate the management of these patients to determine consistency of pain management practices. Secondarily, we aimed to evaluate the documentation of opioid replacement therapy in clinical notes to determine adherence to operational protocols and record clinically relevant outcomes including infection or postoperative complication rates. Forty-four episodes of care for buprenorphine patients and 19 episodes of care for methadone patients were included. There was significant variability in inpatient opioid prescribing, including practice of dose modification, and there was high utilisation of additional opioids, although agent choice varied. Multimodal analgesia was utilised, especially following acute pain service review. There was an 11% readmission rate for complications of the initial presentation. Documentation at transitions of care was poor. There is a need for further clinical studies into specific acute pain management strategies, and their effect on clinically relevant outcomes, to guide consistent management practices.
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Affiliation(s)
- Karla Mayfield
- Sunshine Coast Hospital and Health Service, Birtinya, Australia
| | - Leigh White
- Sunshine Coast Hospital and Health Service, Birtinya, Australia
| | - Timothy Nolan
- Sunshine Coast Hospital and Health Service, Birtinya, Australia
| | - Xavier Conner
- Sunshine Coast Hospital and Health Service, Birtinya, Australia
| | - Brendan Dittmer
- Sunshine Coast Hospital and Health Service, Birtinya, Australia
| | | | - Andrew Mitchell
- Sunshine Coast Hospital and Health Service, Birtinya, Australia
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De Aquino JP, Parida S, Avila-Quintero VJ, Flores J, Compton P, Hickey T, Gómez O, Sofuoglu M. Opioid-induced analgesia among persons with opioid use disorder receiving methadone or buprenorphine: A systematic review of experimental pain studies. Drug Alcohol Depend 2021; 228:109097. [PMID: 34601272 PMCID: PMC8595687 DOI: 10.1016/j.drugalcdep.2021.109097] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/13/2021] [Revised: 09/10/2021] [Accepted: 09/17/2021] [Indexed: 01/25/2023]
Abstract
BACKGROUND Treating acute pain among persons with opioid use disorder (OUD) on opioid agonist therapy (OAT) is complex, and the therapeutic benefits of opioids remain unclear when weighted against their abuse potential and respiratory depressant effects. METHODS We conducted a systematic review of experimental pain studies examining opioid-induced analgesia among persons with OUD on OAT. We searched multiple databases from inception to July 30, 2021. Study quality was assessed by previously established validity measures. RESULTS Nine studies were identified, with a total of 225 participants, of whom 63% were male, and 37% were female. Six studies included methadone-maintained persons with OUD; four studies included buprenorphine-maintained persons with OUD; and three studies included healthy persons as comparison groups. Either additional doses of OAT or other opioids - morphine, oxycodone, hydromorphone, or remifentanil - were administered. In seven studies, persons with OUD on OAT did not experience analgesia, despite receiving opioid doses up to 20 times greater than those clinically used to treat severe pain among the opioid naïve. Conversely, in two studies, high-potency opioids did produce analgesia, albeit with greater abuse potential. Notably, persons with OUD on OAT remained vulnerable to respiratory depression. CONCLUSIONS Although persons with OUD on OAT can derive analgesic effects from opioids, high-potency compounds may be required to achieve clinically significant pain relief. Further, persons with OUD on OAT may remain vulnerable to opioid-induced abuse potential and respiratory depression. Together, these finding have clinical, methodological, and mechanistic implications for the treatment of acute pain in the context of OAT.
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Affiliation(s)
- Joao P De Aquino
- VA Connecticut Healthcare System, 950 Campbell Avenue, Building 36/116A4, West Haven, CT 06516, USA; Yale University School of Medicine, Department of Psychiatry, 300 George Street, New Haven, CT 06511, USA.
| | - Suprit Parida
- VA Connecticut Healthcare System, 950 Campbell Avenue, Building 36/116A4, West Haven, CT 06516, USA; Yale University School of Medicine, Department of Psychiatry, 300 George Street, New Haven, CT 06511, USA
| | - Victor J Avila-Quintero
- Yale University School of Medicine, Department of Psychiatry, 300 George Street, New Haven, CT 06511, USA
| | - Jose Flores
- Yale University School of Medicine, Department of Psychiatry, 300 George Street, New Haven, CT 06511, USA
| | - Peggy Compton
- Department of Family and Community Health, University of Pennsylvania, 418 Curie Boulevard, Room 402, Philadelphia, PA 19104, USA
| | - Thomas Hickey
- VA Connecticut Healthcare System, 950 Campbell Avenue, Building 36/116A4, West Haven, CT 06516, USA; Yale University School of Medicine, Department of Anesthesiology, 333 Cedar Street, New Haven, CT 06520, USA
| | - Oscar Gómez
- Department of Physiological Sciences, Faculty of Medicine, Pontificia Universidad Javeriana, 7th Street, 46-62, Bogota, Colombia
| | - Mehmet Sofuoglu
- VA Connecticut Healthcare System, 950 Campbell Avenue, Building 36/116A4, West Haven, CT 06516, USA; Yale University School of Medicine, Department of Psychiatry, 300 George Street, New Haven, CT 06511, USA
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25
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Kohan L, Potru S, Barreveld A, Sprintz M, Lane O, Aryal A, Emerick T, Dopp A, Chhay S, Viscusi E. Buprenorphine management in the perioperative period: educational review and recommendations from a multisociety expert panel. Reg Anesth Pain Med 2021; 46:840-859. [PMID: 34385292 DOI: 10.1136/rapm-2021-103007] [Citation(s) in RCA: 45] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2021] [Accepted: 07/20/2021] [Indexed: 12/20/2022]
Abstract
BACKGROUND The past two decades have witnessed an epidemic of opioid use disorder (OUD) in the USA, resulting in catastrophic loss of life secondary to opioid overdoses. Medication treatment of opioid use disorder (MOUD) is effective, yet barriers to care continue to result in a large proportion of untreated individuals. Optimal analgesia can be obtained in patients with MOUD within the perioperative period. Anesthesiologists and pain physicians can recommend and consider initiating MOUD in patients with suspected OUD at the point of care; this can serve as a bridge to comprehensive treatment and ultimately save lives. METHODS The Board of Directors of the American Society of Regional Anesthesia and Pain Medicine, American Society of Anesthesiologists, American Academy of Pain Medicine, American Society of Addiction Medicine and American Society of Health System Pharmacists approved the creation of a Multisociety Working Group on Opioid Use Disorder, representing the fields of pain medicine, addiction, and pharmacy health sciences. An extensive literature search was performed by members of the working group. Multiple study types were included and reviewed for quality. A modified Delphi process was used to assess the literature and expert opinion for each topic, with 100% consensus being achieved on the statements and each recommendation. The consensus statements were then graded by the committee members using the United States Preventive Services Task Force grading of evidence guidelines. In addition to the consensus recommendations, a narrative overview of buprenorphine, including pharmacology and legal statutes, was performed. RESULTS Two core topics were identified for the development of recommendations with >75% consensus as the goal for consensus; however, the working group achieved 100% consensus on both topics. Specific topics included (1) providing recommendations to aid physicians in the management of patients receiving buprenorphine for MOUD in the perioperative setting and (2) providing recommendations to aid physicians in the initiation of buprenorphine in patients with suspected OUD in the perioperative setting. CONCLUSIONS To decrease the risk of OUD recurrence, buprenorphine should not be routinely discontinued in the perioperative setting. 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.
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Affiliation(s)
- Lynn Kohan
- Division of Pain Medicine/Department of Anesthesia, University of Virginia, Charlottesville, Virginia, USA
| | - Sudheer Potru
- Atlanta VA Medical Center, Emory University School of Medicine, Atlanta, Georgia, USA.,Department of Anesthesiology, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Antje Barreveld
- Tufts University School of Medicine-and Newton Wesley Hospital, Boston and Newton, Massachusetts, USA
| | - Michael Sprintz
- Division of Geriatrics and Palliative Medicine, The University of Texas Health Science Center at Houston, Houston, Texas, USA
| | - Olabisi Lane
- Division of Pain Medicine, Department of Anestheisology, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Anuj Aryal
- Cedar Recovery and Deparment of Anesthesiolgy and Pain Medicine, VA Tennessee Valley Healthcare System Nashville Campus, Nashville, Tennessee, USA
| | - Trent Emerick
- Department of Anesthesiolgoy and Perioperative Medicine, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Anna Dopp
- American Society Health System Pharmacists, Bethesda, Maryland, USA
| | - Sophia Chhay
- American Society Health System Pharmacists, Bethesda, Maryland, USA
| | - Eugene Viscusi
- Thomas Jefferson University Sidney Kimmel Medical College, Philadelphia, Pennsylvania, USA
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26
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Macintyre PE. The opioid epidemic from the acute care hospital front line. Anaesth Intensive Care 2021; 50:29-43. [PMID: 34348484 DOI: 10.1177/0310057x211018211] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
Prescription opioid use has risen steeply for over two decades, driven primarily by advocacy for better management of chronic non-cancer pain, but also by poor opioid stewardship in the management of acute pain. Inappropriate prescribing, among other things, contributed to the opioid 'epidemic' and striking increases in patient harm. It has also seen a greater proportion of opioid-tolerant patients presenting to acute care hospitals. Effective and safe management of acute pain in opioid-tolerant patients can be challenging, with higher risks of opioid-induced ventilatory impairment and persistent post-discharge opioid use compared with opioid-naive patients. There are also increased risks of some less well known adverse postoperative outcomes including infection, earlier revision rates after major joint arthroplasty and spinal fusion, longer hospital stays, higher re-admission rates and increased healthcare costs. Increasingly, opioid-free/opioid-sparing techniques have been advocated as ways to reduce patient harm. However, good evidence for these remains lacking and opioids will continue to play an important role in the management of acute pain in many patients.Better opioid stewardship with consideration of preoperative opioid weaning in some patients, assessment of patient function rather than relying on pain scores alone to assess adequacy of analgesia, prescription of immediate release opioids only and evidence-based use of analgesic adjuvants are important. Post-discharge opioid prescribing should be contingent on an assessment of patient risk, with short-term only use of opioids. In partnership with pharmacists, nursing staff, other medical specialists, general practitioners and patients, anaesthetists remain ideally positioned to be involved in opioid stewardship in the acute care setting.
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Affiliation(s)
- Pamela E Macintyre
- Department of Anaesthesia, Pain Medicine and Hyperbaric Medicine, Royal Adelaide Hospital, Adelaide, Australia.,Discipline of Acute Care Medicine, University of Adelaide, Adelaide, Australia
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27
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Advanced Inpatient Management of Opioid Use Disorder in a Patient Requiring Serial Surgeries. J Gen Intern Med 2021; 36:2448-2451. [PMID: 33782885 PMCID: PMC8342648 DOI: 10.1007/s11606-021-06739-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/14/2020] [Revised: 01/27/2021] [Accepted: 03/17/2021] [Indexed: 10/21/2022]
Abstract
Opioid use disorder has affected many lives across the US. Medications for opioid use disorder (MOUD), including buprenorphine, have been shown to decrease mortality in this patient population. Here we present a case of a 32-year-old woman on buprenorphine/naloxone undergoing multiple surgical operations, whose course included buprenorphine discontinuation, methadone initiation, and buprenorphine re-induction using a novel "microdosing" approach. This report includes a presentation of the case and a discussion of the clinical decision making and relevant literature to give hospitalbased providers a perspective on management of peri-operative patients on MOUD.
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28
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Levy N, Quinlan J, El-Boghdadly K, Fawcett WJ, Agarwal V, Bastable RB, Cox FJ, de Boer HD, Dowdy SC, Hattingh K, Knaggs RD, Mariano ER, Pelosi P, Scott MJ, Lobo DN, Macintyre PE. An international multidisciplinary consensus statement on the prevention of opioid-related harm in adult surgical patients. Anaesthesia 2021; 76:520-536. [PMID: 33027841 DOI: 10.1111/anae.15262] [Citation(s) in RCA: 87] [Impact Index Per Article: 29.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/29/2020] [Indexed: 01/01/2023]
Abstract
This international multidisciplinary consensus statement was developed to provide balanced guidance on the safe peri-operative use of opioids in adults. An international panel of healthcare professionals evaluated the literature relating to postoperative opioid-related harm, including persistent postoperative opioid use; opioid-induced ventilatory impairment; non-medical opioid use; opioid diversion and dependence; and driving under the influence of prescription opioids. Recommended strategies to reduce harm include pre-operative assessment of the risk of persistent postoperative opioid use; use of an assessment of patient function rather than unidimensional pain scores alone to guide adequacy of analgesia; avoidance of long-acting (modified-release and transdermal patches) opioid formulations and combination analgesics; limiting the number of tablets prescribed at discharge; providing deprescribing advice; avoidance of automatic prescription refills; safe disposal of unused medicines; reducing the risk of opioid diversion; and better education of healthcare professionals, patients and carers. This consensus statement provides a framework for better prescribing practices that could help reduce the risk of postoperative opioid-related harm in adults.
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Affiliation(s)
- N Levy
- Department of Anaesthesia and Peri-operative Medicine, West Suffolk Hospital, Bury St. Edmunds, UK
| | - J Quinlan
- Nuffield Department of Anaesthetics, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - K El-Boghdadly
- Department of Anaesthesia, Guy's and St Thomas' NHS Foundation Trust, London, UK
- King's College London, London, UK
| | - W J Fawcett
- Department of Anaesthesia and Pain Medicine, Royal Surrey County Hospital NHS Foundation Trust, Guildford, UK
| | - V Agarwal
- Department of Anaesthesia, Critical Care and Pain, Tata Memorial Centre, Homi Bhabha National Institute, Mumbai, Maharashtra, India
| | | | - F J Cox
- Pain Management Service, Critical Care and Anaesthesia, Royal Brompton and Harefield NHS Foundation Trust, London, UK
| | - H D de Boer
- Department of Anaesthesiology, Pain Medicine and Procedural Sedation and Analgesia, Martini General Hospital Groningen, Groningen, The Netherlands
| | - S C Dowdy
- Division of Gynecologic Oncology, Mayo Clinic, Rochester, MN, USA
| | - K Hattingh
- Bendigo Health, Bendigo, Victoria, Australia
| | - R D Knaggs
- School of Pharmacy, Pain Centre Versus Arthritis, University of Nottingham, Nottingham, UK
| | - E R Mariano
- Department of Anesthesiology, Peri-operative and Pain Medicine, Stanford University School of Medicine, Stanford, CA, USA
- Anesthesiology and Peri-operative Care Service, Veterans Affairs Palo Alto Health Care System, Palo Alto, CA, USA
| | - P Pelosi
- Department of Surgical Sciences and Integrated Diagnostics, University of Genoa, Genoa, Italy
- IRCCS for Oncology and Neurosciences, San Martino Policlinico Hospital, Genoa, Italy
| | - M J Scott
- Anesthesiology and Critical Care Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - D N Lobo
- Gastrointestinal Surgery, Nottingham Digestive Diseases Centre, National Institute for Health Research (NIHR) Nottingham Biomedical Research Centre, Nottingham University Hospitals NHS Trust and University of Nottingham, Queen's Medical Centre, Nottingham, UK
- David Greenfield Metabolic Physiology Unit, MRC Versus Arthritis Centre for Musculoskeletal Ageing Research, School of Life Sciences, University of Nottingham, Queen's Medical Centre, Nottingham, UK
| | - P E Macintyre
- Department of Anaesthesia, Pain Medicine and Hyperbaric Medicine, Royal Adelaide Hospital and University of Adelaide, Adelaide, South Australia, Australia
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29
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Peckham AM, Ball J, Colvard MD, Dadiomov D, Hill LG, Nichols SD, Tallian K, Ventricelli DJ, Tran TH. Leveraging pharmacists to maintain and extend buprenorphine supply for opioid use disorder amid COVID-19 pandemic. Am J Health Syst Pharm 2021; 78:613-618. [PMID: 33411894 PMCID: PMC7929456 DOI: 10.1093/ajhp/zxab003] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023] Open
Abstract
Purpose Strategies for deploying clinical pharmacists to increase access to buprenorphine in inpatient, outpatient and transitional care, and community practice settings are described. Summary Access to medications for opioid use disorder (MOUD) is essential, but patients face many barriers when pursuing treatment and MOUD. The coronavirus disease 2019 (COVID-19) pandemic has compounded the opioid crisis and worsened outcomes by introducing new barriers to MOUD access. Many strategies to ensure continued access to MOUD have been described, but the role of leveraging pharmacists during the opioid/COVID-19 syndemic to improve medication access and outcomes remains underappreciated. Pharmacists, while both qualified and capable of liberalizing access to all forms of MOUD, may have the strongest impact by increasing access to buprenorphine. Herein, we present progressive strategies to maintain and extend buprenorphine access for patients with OUD through deployment of clinical pharmacists, particularly in the context of the COVID-19 pandemic, during which access may be further restricted. Conclusion Leveraging pharmacists to extend access to MOUD, particularly buprenorphine, remains an underutilized strategy that should be implemented, particularly during the concurrent COVID-19 global pandemic.
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Affiliation(s)
- Alyssa M Peckham
- Northeastern University School of Pharmacy, Boston, MA.,Massachusetts General Hospital Substance Use Disorders Initiative, Boston, MA, USA
| | - Jennifer Ball
- South Dakota State University College of Pharmacy and Allied Health Professions, Brookings, SD.,University of South Dakota School of Medicine, Vermillion, SD, USA
| | - Michelle D Colvard
- Substance Use Disorder Transitions of Care Clinic, Inpatient Psychiatry and Addiction Services, VA Tennessee Valley Healthcare System, Nashville, TN, USA
| | - David Dadiomov
- University of Southern California School of Pharmacy, Los Angeles, CA, and Los Angeles County Department of Health Services, Los Angeles, CA, USA
| | - Lucas G Hill
- University of Texas at Austin College of Pharmacy, Austin, TX, USA
| | - Stephanie D Nichols
- University of New England College of Pharmacy, Portland, ME, and Maine Medical Center Consult-Liaison Service, Portland, ME, USA
| | | | - Daniel J Ventricelli
- Philadelphia College of Pharmacy, University of the Sciences, Philadelphia, PA, USA
| | - Tran H Tran
- Chicago Midwestern University, Chicago College of Pharmacy, Downers Grove, IL.,Rush University Medical Center Substance Use Intervention Team, Chicago, IL, USA
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30
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Hyland SJ, Brockhaus KK, Vincent WR, Spence NZ, Lucki MM, Howkins MJ, Cleary RK. Perioperative Pain Management and Opioid Stewardship: A Practical Guide. Healthcare (Basel) 2021; 9:333. [PMID: 33809571 PMCID: PMC8001960 DOI: 10.3390/healthcare9030333] [Citation(s) in RCA: 58] [Impact Index Per Article: 19.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2021] [Revised: 03/02/2021] [Accepted: 03/10/2021] [Indexed: 12/20/2022] Open
Abstract
Surgical procedures are key drivers of pain development and opioid utilization globally. Various organizations have generated guidance on postoperative pain management, enhanced recovery strategies, multimodal analgesic and anesthetic techniques, and postoperative opioid prescribing. Still, comprehensive integration of these recommendations into standard practice at the institutional level remains elusive, and persistent postoperative pain and opioid use pose significant societal burdens. The multitude of guidance publications, many different healthcare providers involved in executing them, evolution of surgical technique, and complexities of perioperative care transitions all represent challenges to process improvement. This review seeks to summarize and integrate key recommendations into a "roadmap" for institutional adoption of perioperative analgesic and opioid optimization strategies. We present a brief review of applicable statistics and definitions as impetus for prioritizing both analgesia and opioid exposure in surgical quality improvement. We then review recommended modalities at each phase of perioperative care. We showcase the value of interprofessional collaboration in implementing and sustaining perioperative performance measures related to pain management and analgesic exposure, including those from the patient perspective. Surgery centers across the globe should adopt an integrated, collaborative approach to the twin goals of optimal pain management and opioid stewardship across the care continuum.
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Affiliation(s)
- Sara J. Hyland
- Department of Pharmacy, Grant Medical Center (OhioHealth), Columbus, OH 43215, USA
| | - Kara K. Brockhaus
- Department of Pharmacy, St. Joseph Mercy Hospital Ann Arbor, Ypsilanti, MI 48197, USA;
| | | | - Nicole Z. Spence
- Department of Anesthesiology, Boston University School of Medicine, Boston Medical Center, Boston, MA 02118, USA;
| | - Michelle M. Lucki
- Department of Orthopedics, Grant Medical Center (OhioHealth), Columbus, OH 43215, USA;
| | - Michael J. Howkins
- Department of Addiction Medicine, Grant Medical Center (OhioHealth), Columbus, OH 43215, USA;
| | - Robert K. Cleary
- Department of Surgery, St. Joseph Mercy Hospital Ann Arbor, Ypsilanti, MI 48197, USA;
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31
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Buresh M, Ratner J, Zgierska A, Gordin V, Alvanzo A. Treating Perioperative and Acute Pain in Patients on Buprenorphine: Narrative Literature Review and Practice Recommendations. J Gen Intern Med 2020; 35:3635-3643. [PMID: 32827109 PMCID: PMC7728902 DOI: 10.1007/s11606-020-06115-3] [Citation(s) in RCA: 25] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/28/2020] [Accepted: 08/05/2020] [Indexed: 02/07/2023]
Abstract
Opioid use disorder (OUD), a leading cause of morbidity and mortality in the USA, can be effectively treated with buprenorphine. However, the same pharmacologic properties (e.g., high affinity, partial agonism, long half-life) that make it ideal as a treatment for OUD often cause concern among clinicians that buprenorphine will prevent effective management of acute pain with full agonist opioid analgesics. Because of this concern, many patients are asked to stop buprenorphine preoperatively or at the onset of acute pain, placing them at high risk for both relapse and a difficult transition back to buprenorphine after acute pain has resolved. The purpose of this review is to summarize the existing literature for acute pain and perioperative management in patients treated with buprenorphine for OUD and to provide practical management recommendations for generalist practitioners based on evidence and clinical experience. In short, evidence suggests that sufficient analgesia can be achieved with maintenance of buprenorphine and use of both opioid and non-opioid analgesic options for breakthrough pain. We recommend that clinicians (1) continue buprenorphine in the perioperative or acute pain period for patients with OUD; (2) use a multi-modal analgesic approach; (3) pay attention to care coordination and discharge planning when making an analgesic plan for patients with OUD treated with buprenorphine; and (4) use an individualized approach founded upon shared decision-making. Clinical examples involving mild and severe pain are discussed to highlight important management principles.
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Affiliation(s)
- Megan Buresh
- Division of Addiction Medicine, Johns Hopkins School of Medicine, Baltimore, MD, USA.
| | - Jessica Ratner
- Division of Addiction Medicine, Johns Hopkins School of Medicine, Baltimore, MD, USA
| | - Aleksandra Zgierska
- Department of Family and Community Medicine, Penn State College of Medicine, Hershey, PA, USA
- Department of Anesthesiology and Perioperative Medicine, Penn State Hershey Medical Center, Hershey, PA, USA
| | - Vitaly Gordin
- Department of Anesthesiology and Perioperative Medicine, Penn State Hershey Medical Center, Hershey, PA, USA
| | - Anika Alvanzo
- Divisions of General Internal Medicine and Addiction Medicine, Johns Hopkins School of Medicine, Baltimore, MD, USA
- Pyramid Healthcare, Inc., Duncansville, PA, USA
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32
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Veazie S, Mackey K, Peterson K, Bourne D. Managing Acute Pain in Patients Taking Medication for Opioid Use Disorder: a Rapid Review. J Gen Intern Med 2020; 35:945-953. [PMID: 33145688 PMCID: PMC7728869 DOI: 10.1007/s11606-020-06256-5] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/07/2020] [Accepted: 09/18/2020] [Indexed: 12/29/2022]
Abstract
BACKGROUND Managing acute pain in patients with opioid use disorder (OUD) on medication (methadone, buprenorphine, or naltrexone) can be complicated by patients' higher baseline pain sensitivity and need for higher opioid doses to achieve pain relief. This review aims to evaluate the benefits and harms of acute pain management strategies for patients taking OUD medications and whether strategies vary by OUD medication type or cause of acute pain. METHODS We systematically searched multiple bibliographic sources until April 2020. One reviewer used prespecified criteria to assess articles for inclusion, extract data, rate study quality, and grade our confidence in the body of evidence, all with second reviewer checking. RESULTS We identified 12 observational studies-3 with control groups and 9 without. Two of the studies with control groups suggest that continuing buprenorphine and methadone in OUD patients after surgery may reduce the need for additional opioids and that ineffective pain management in patients taking methadone can result in disengagement in care. A third controlled study found that patients taking OUD medications may need higher doses of additional opioids for pain control, but provided insufficient detail to apply results to clinic practice. The only case study examining naltrexone reported that postoperative pain was managed using tramadol. We have low confidence in these findings as no studies directly addressed our question by comparing pain management strategies and few provided adequate descriptions of the dosage, timing, or rationale for clinical decisions. DISCUSSION We lack rigorous evidence on acute pain management in patients taking medication for OUD; however, evidence supports the practice of continuing methadone or buprenorphine for most patients during acute pain episodes. Well-described, prospective studies of adjuvant pain management strategies when OUD medications are continued would add to the existing literature base. Studies on nonopioid treatments are also needed for patients taking naltrexone. PROTOCOL REGISTRATION PROSPERO; CRD42019132924.
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Affiliation(s)
- Stephanie Veazie
- Evidence Synthesis Program (ESP) Coordinating Center, VA Portland Health Care System, Portland, OR, USA.
| | - Katherine Mackey
- Evidence Synthesis Program (ESP) Coordinating Center, VA Portland Health Care System, Portland, OR, USA
| | - Kim Peterson
- Evidence Synthesis Program (ESP) Coordinating Center, VA Portland Health Care System, Portland, OR, USA
| | - Donald Bourne
- Evidence Synthesis Program (ESP) Coordinating Center, VA Portland Health Care System, Portland, OR, USA
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33
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Pain Management in the Unstable Trauma Patient. CURRENT TRAUMA REPORTS 2020. [DOI: 10.1007/s40719-020-00197-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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34
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Somogyi AA, Athanasos P, White J, Bochner F, Ling W. Buprenorphine Maintenance Subjects Are Hyperalgesic and Have No Antinociceptive Response to a Very High Morphine Dose. PAIN MEDICINE 2020; 21:2007-2008. [PMID: 32289823 DOI: 10.1093/pm/pnaa067] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Affiliation(s)
- Andrew A Somogyi
- Discipline of Pharmacology, Adelaide Medical School, University of Adelaide, Adelaide, Australia
| | - Peter Athanasos
- Emergency Department, Mental Health Short Stay Unit, The Queen Elizabeth Hospital, Adelaide, Australia
| | - Jason White
- School of Pharmacy and Medical Sciences, University of South Australia, Adelaide, Australia
| | - Felix Bochner
- Discipline of Pharmacology, Adelaide Medical School, University of Adelaide, Adelaide, Australia
| | - Walter Ling
- Department of Family Medicine, Center for Behavioral and Addiction Medicine, David Geffen School of Medicine, UCLA, Los Angeles, California, USA
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35
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Quaye ANA, Zhang Y. Perioperative Management of Buprenorphine: Solving the Conundrum. PAIN MEDICINE 2020; 20:1395-1408. [PMID: 30500943 DOI: 10.1093/pm/pny217] [Citation(s) in RCA: 43] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
OBJECTIVE There is no consensus on the optimal perioperative management of patients on buprenorphine (BUP) for opioid use disorder (OUD). This article will review the available literature on BUP and the analgesic efficacy of BUP combined with full mu-opioid agonists and discuss the conflicting management strategies in the context of acute pain and our institution's protocol for the periprocedural management of BUP. METHODS We searched published data on BUP periprocedural management from inception through March 2018 without language restrictions. Study selection included publications reporting outcomes on perioperative pain management in OUD patients maintained on BUP. RESULTS Our search resulted in four case reports supporting periprocedural discontinuation of BUP and two case series, one secondary observational study, one prospective matched cohort study, and four retrospective cohort studies supporting periprocedural continuation of BUP. No clinical trials were identified. CONCLUSIONS Maintaining BUP perioperatively does not lead to worsened clinical outcomes. Patients can receive adequate pain control from mu-opioid agonists while maintained on BUP. Based upon available evidence, we recommend continuing BUP at a reduced dose when indicated to avoid withdrawal symptoms and to facilitate the analgesic efficacy of mu-opioid agonists administered in combination for acute postoperative pain.
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Affiliation(s)
- Aurora Naa-Afoley Quaye
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Yi Zhang
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
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36
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Herscher M, Fine M, Navalurkar R, Hirt L, Wang L. Diagnosis and Management of Opioid Use Disorder in Hospitalized Patients. Med Clin North Am 2020; 104:695-708. [PMID: 32505261 DOI: 10.1016/j.mcna.2020.03.003] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
The diagnosis of opioid use disorder (OUD) is often overlooked or inadequately managed during the inpatient admission. When recognized, a common strategy is opioid detoxification, an approach that is often ineffective and can be potentially dangerous because of loss of tolerance and subsequent risk for overdose. Medication for addiction treatment (MAT), including methadone and buprenorphine, is effective and can be dispensed in the hospital for both opioid withdrawal and initiation of maintenance treatment. Hospitalists should be knowledgeable about diagnosing and managing patients with OUD, including how to manage acute pain or MAT during the perioperative setting.
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Affiliation(s)
- Michael Herscher
- Division of Hospital Medicine, Department of Medicine, Icahn School of Medicine at Mount Sinai, 1 Gustave Levy Place, New York, NY 10029, USA.
| | - Matthew Fine
- Department of Medical Education, Icahn School of Medicine at Mount Sinai, 1 Gustave Levy Place, New York, NY 10029, USA
| | - Reema Navalurkar
- Department of Medical Education, Icahn School of Medicine at Mount Sinai, 1 Gustave Levy Place, New York, NY 10029, USA
| | - Leeza Hirt
- Department of Medical Education, Icahn School of Medicine at Mount Sinai, 1 Gustave Levy Place, New York, NY 10029, USA
| | - Linda Wang
- Division of General Internal Medicine, Department of Medicine, Icahn School of Medicine at Mount Sinai, 1 Gustave Levy Place, New York, NY 10029, USA
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Abstract
OBJECTIVE Given there are conflicting recommendations for the perioperative management of buprenorphine, we conducted a retrospective cohort study of our surgery patients on buprenorphine whose baseline dose had been preoperatively continued, tapered, or discontinued. MATERIALS AND METHODS We reviewed charts of patients on buprenorphine who had received elective surgery at Stanford Healthcare from January 1, 2013 to June 30, 2016. Our primary outcome of interest was the change in pain score, defined as mean postoperative pain score-preoperative pain score. We also collected data on patients' tapering procedure and any postoperative nonbuprenorphine opioid requirements. RESULTS Out of ∼1200 patients on buprenorphine, 121 had surgery of which 50 were admitted and included in the study. Perioperative continuation of transdermal buprenorphine resulted in a significantly lower change in pain score postoperatively (0.606±0.878) than discontinuation (4.83±1.23, P=0.012). Among sublingual patients, there was no statistically significant difference in the change in pain score between those who were tapered to a nonzero dose versus discontinued (P=0.55). Continuation of sublingual buprenorphine resulted in fewer nonbuprenorphine scheduled opioid prescriptions than its taper or discontinuation (P=0.028). Finally, tapers were performed with great variability in the tapering team and rate of taper. DISCUSSION On the basis of our findings, we implemented a policy at our institution for the continuation of perioperative buprenorphine whenever possible. Our work reveals crucial targets for the education of perioperative healthcare providers and the importance of coordination among all perioperative services and providers.
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Warner NS, Warner MA, Cunningham JL, Gazelka HM, Hooten WM, Kolla BP, Warner DO. A Practical Approach for the Management of the Mixed Opioid Agonist-Antagonist Buprenorphine During Acute Pain and Surgery. Mayo Clin Proc 2020; 95:1253-1267. [PMID: 32061413 DOI: 10.1016/j.mayocp.2019.10.007] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/24/2019] [Revised: 09/20/2019] [Accepted: 10/11/2019] [Indexed: 02/06/2023]
Abstract
The use of buprenorphine, a mixed opioid agonist-antagonist, for the management of chronic pain and/or opioid use disorder is increasing. As such, medical providers will more frequently encounter patients on this therapy. In this paper, we synthesize existing knowledge (derived through keyword searches using MEDLINE databases) in a novel conceptual framework for patients on buprenorphine presenting with acute pain or for those requiring surgical or invasive procedures. This framework is based on three unique domains: the patient, the features of the acute pain insult, and the environment. We discuss important considerations regarding the unique aspects of buprenorphine formulations and dosing, and we describe the importance of multidisciplinary planning and multimodal analgesic strategies. We also highlight important differences in management strategies based upon the presence or absence of opioid use disorder. All medical providers must be prepared to guide the patient on buprenorphine safely through the acute care episode, which includes adequate treatment of acute pain and avoidance of iatrogenic harm, including both short-term complications (eg, respiratory depression) and long-term complications (eg, relapse to opioid use).
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Affiliation(s)
- Nafisseh S Warner
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, MN; Division of Pain Medicine, Mayo Clinic, Rochester, MN; Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, MN.
| | - Matthew A Warner
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, MN; Division of Critical Care Medicine, Mayo Clinic, Rochester, MN
| | | | - Halena M Gazelka
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, MN; Division of Pain Medicine, Mayo Clinic, Rochester, MN
| | - W Michael Hooten
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, MN; Division of Pain Medicine, Mayo Clinic, Rochester, MN
| | | | - David O Warner
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, MN; Division of Pediatric Anesthesiology, Mayo Clinic, Rochester, MN
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Sritapan Y, Clifford S, Bautista A. Perioperative Management of Patients on Buprenorphine and Methadone: A Narrative Review. Balkan Med J 2020; 37:247-252. [PMID: 32407063 PMCID: PMC7424191 DOI: 10.4274/balkanmedj.galenos.2020.2020.5.2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
The opioid epidemic has emerged as a major health and social problem over the last few decades. An increasing number of patients with opioid use disorder are presenting for perioperative management. These patients are either on buprenorphine or methadone for the maintenance and treatment of opioid addiction or chronic pain. In the settings of acute pain, the optimal management of patients with opioid use disorder is challenging, and recovery can be jeopardized secondary to the unique pharmacology of these agents. The purpose of this narrative review is to summarize the existing studies on the perioperative management of patients who are using buprenorphine and methadone and provide guidance for the management of patients with opioid use disorder during the perioperative period.
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Affiliation(s)
- Yasmin Sritapan
- Department of Anesthesiology and Perioperative Medicine, University of Louisville, Louisville, Kentucky, USA
| | - Sean Clifford
- Department of Anesthesiology and Perioperative Medicine, University of Louisville, Louisville, Kentucky, USA
| | - Alexander Bautista
- Department of Anesthesiology and Perioperative Medicine, University of Louisville, Louisville, Kentucky, USA
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Webster L, Gudin J, Raffa RB, Kuchera J, Rauck R, Fudin J, Adler J, Mallick-Searle T. Understanding Buprenorphine for Use in Chronic Pain: Expert Opinion. PAIN MEDICINE (MALDEN, MASS.) 2020; 21:714-723. [PMID: 31917418 PMCID: PMC7139205 DOI: 10.1093/pm/pnz356] [Citation(s) in RCA: 56] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
OBJECTIVE An expert panel convened to reach a consensus on common misconceptions surrounding buprenorphine, a Schedule III partial µ-opioid receptor agonist indicated for chronic pain. The panel also provided clinical recommendations on the appropriate use of buprenorphine and conversion strategies for switching to buprenorphine from a full µ-opioid receptor agonist for chronic pain management. METHODS The consensus panel met on March 25, 2019, to discuss relevant literature and provide recommendations on interpreting buprenorphine as a partial µ-opioid receptor agonist, prescribing buprenorphine before some Schedule II, III, or IV options, perioperative/trauma management of patients taking buprenorphine, and converting patients from a full µ-opioid receptor agonist to buprenorphine. RESULTS The panel recommended that buprenorphine's classification as a partial µ-opioid receptor agonist not be clinically translated to mean partial analgesic efficacy. The panel also recommended that buprenorphine be considered before some Schedule II, III, or IV opioids in patients with a favorable risk/benefit profile on the basis of metabolic factors, abuse potential, and tolerability and that buprenorphine be continued during the perioperative/trauma period. In addition, switching patients from a full µ-opioid receptor agonist to buprenorphine should be considered with no weaning period at starting doses that are based on the previous opioid dose. CONCLUSIONS These recommendations provide a framework for clinicians to address most clinical scenarios regarding buprenorphine use. The overall consensus of the panel was that buprenorphine is a unique Schedule III opioid with favorable pharmacologic properties and a safety profile that may be desirable for chronic pain management.
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Affiliation(s)
| | - Jeffrey Gudin
- Department of Anesthesiology and Pain Management, Englewood Hospital and Medical Center, Englewood, New Jersey; Rutgers New Jersey Medical School, Newark, New Jersey
| | - Robert B Raffa
- College of Pharmacy, The University of Arizona Health Sciences, Tucson, Arizona
- Temple University School of Pharmacy, Philadelphia, Pennsylvania; Neumentum Inc, Palo Alto, California
| | - Jay Kuchera
- Resolute Pain Solutions, Okeechobee, Florida
| | - Richard Rauck
- Carolinas Pain Institute, Winston-Salem, North Carolina
| | - Jeffrey Fudin
- Remitigate LLC, Delmar, New York; Western New England University College of Pharmacy, Springfield, Massachusetts
- Albany College of Pharmacy & Health Sciences, Albany, New York
| | - Jeremy Adler
- Pacific Pain Medicine Consultants, Encinitas, California
| | - Theresa Mallick-Searle
- Division of Pain Medicine, Stanford Medicine Outpatient Center, Redwood City, California, USA
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41
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Macintyre PE, Roberts LJ, Huxtable CA. Management of Opioid-Tolerant Patients with Acute Pain: Approaching the Challenges. Drugs 2019; 80:9-21. [DOI: 10.1007/s40265-019-01236-4] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
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Scholzen E, Zeng AM, Schroeder KM. Perioperative Management and Analgesia for Patients Taking Buprenorphine and Other Forms of Medication-Assisted Treatment for Substance Abuse Disorders. Adv Anesth 2019; 37:65-86. [PMID: 31677660 DOI: 10.1016/j.aan.2019.08.002] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Affiliation(s)
- Elizabeth Scholzen
- Department of Anesthesiology, University of Wisconsin School of Medicine and Public Health, University of Wisconsin, 600 Highland Avenue, B6/319 CSC, Madison, WI 53792, USA
| | - Angela M Zeng
- Department of Anesthesiology, University of Wisconsin School of Medicine and Public Health, University of Wisconsin, 600 Highland Avenue, B6/319 CSC, Madison, WI 53792, USA
| | - Kristopher M Schroeder
- Department of Anesthesiology, University of Wisconsin School of Medicine and Public Health, University of Wisconsin, 600 Highland Avenue, B6/319 CSC, Madison, WI 53792, USA.
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43
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Cooper R, Vanjani R, Trimbur MC. Acute Pain Management in Patients Treated With Buprenorphine: A Teachable Moment. JAMA Intern Med 2019; 179:1415-1416. [PMID: 31355876 DOI: 10.1001/jamainternmed.2019.3103] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Affiliation(s)
- Rachel Cooper
- Department of Medicine, Warren Alpert Medical School, Brown University, Providence, Rhode Island
| | - Rahul Vanjani
- Division of General Internal Medicine, Warren Alpert Medical School, Brown University, Providence, Rhode Island
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Murnion BP, Rivas C, Demirkol A, Hayes V, Lintzeris N, Nielsen S. Acute Experimental Pain Responses in Methadone- and Buprenorphine/Naloxone-Maintained Patients Administered Additional Opioid or Gabapentin: A Double-Blind Crossover Pilot Study. PAIN MEDICINE 2019; 21:1188-1198. [DOI: 10.1093/pm/pnz178] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Abstract
Objective
The study objective was to identify the analgesic efficacy of three different pharmacological strategies in patients receiving methadone or buprenorphine as opioid agonist treatment (OAT). The three pharmacological approaches, a) increasing maintenance methadone/buprenorphine dose by 30%, b) adding oxycodone, or c) adding a single dose of gabapentin, were compared with a control condition of the participant’s usual OAT dose.
Design
A randomized, controlled, double-blinded, double-dummy, within-subject crossover study.
Subjects
Nine participants on stable doses of methadone and eight participants on stable doses of buprenorphine were recruited.
Setting
An outpatient opioid treatment clinic in inner city Sydney, Australia.
Methods
The cold pressor tolerance test was used to examine experimental pain threshold and tolerance. Ratings of subjective drug effects and safety measures (physiological and cognitive) were assessed.
Results
There was no difference in the primary outcome measures of pain thresholds or tolerance between the conditions examined. Interindividual variability was evident. Differences in some subjective measures were identified, including lower pain recall, lower “bad effects,” and higher global satisfaction in the additional methadone condition. In the buprenorphine arm, increased drug liking and “bad effects” were detected with oxycodone administration, while increased subjective intoxication was identified with gabapentin.
Conclusions
There was no evidence of an objective improvement in analgesia with any condition compared with control. Further research is required to optimize pain management strategies in this population.
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Affiliation(s)
- Bridin Patricia Murnion
- Drug and Alcohol Services, Central Coast Local Health District, Hamlyn Terrace, Australia
- Faculty of Health and Medicine, University of Newcastle, Newcastle, Australia
| | - Consuelo Rivas
- Drug and Alcohol Services, South Eastern Sydney Local Health District, Sydney, Australia
| | - Apo Demirkol
- Drug and Alcohol Services, South Eastern Sydney Local Health District, Sydney, Australia
| | - Vicky Hayes
- Drug and Alcohol Services, South Eastern Sydney Local Health District, Sydney, Australia
| | - Nicholas Lintzeris
- Drug and Alcohol Services, South Eastern Sydney Local Health District, Sydney, Australia
- National Drug and Alcohol Centre, University of New South Wales, Sydney, Australia
- Discipline of Addiction Medicine, University of Sydney, Sydney, Australia
| | - Suzanne Nielsen
- Drug and Alcohol Services, South Eastern Sydney Local Health District, Sydney, Australia
- National Drug and Alcohol Centre, University of New South Wales, Sydney, Australia
- Monash Addiction Research Centre, Monash University, Melbourne, Australia
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46
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Athanasos P, Ling W, Bochner F, White JM, Somogyi AA. Buprenorphine Maintenance Subjects Are Hyperalgesic and Have No Antinociceptive Response to a Very High Morphine Dose. PAIN MEDICINE 2019. [PMID: 29514333 DOI: 10.1093/pm/pny025] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
Objective Acute pain management in opioid-dependent persons is complicated because of tolerance and opioid-induced hyperalgesia. Very high doses of morphine are ineffective in overcoming opioid-induced hyperalgesia and providing antinociception to methadone-maintained patients in an experimental setting. Whether the same occurs in buprenorphine-maintained subjects is unknown. Design Randomized double-blind placebo-controlled. Subjects were tested on two occasions, at least five days apart, once with intravenous morphine and once with intravenous saline. Subjects were tested at about the time of putative trough plasma buprenorphine concentrations. Setting Ambulatory. Subjects Twelve buprenorphine-maintained subjects: once daily sublingual dose (range = 2-22 mg); no dose change for 1.5-12 months. Ten healthy controls. Methods Intravenous morphine bolus and infusions administered over two hours to achieve two separate pseudo-steady-state plasma concentrations one hour apart. Pain tolerance was assessed by application of nociceptive stimuli (cold pressor [seconds] and electrical stimulation [volts]). Ten blood samples were collected for assay of plasma morphine, buprenorphine, and norbuprenorphine concentrations until three hours after the end of the last infusion; pain tolerance and respiration rate were measured to coincide with blood sampling times. Results Cold pressor responses (seconds): baseline: control 34 ± 6 vs buprenorphine 17 ± 2 (P = 0.009); morphine infusion-end: control 52 ± 11(P = 0.04), buprenorphine 17 ± 2 (P > 0.5); electrical stimulation responses (volts): baseline: control 65 ± 6 vs buprenorphine 53 ± 5 (P = 0.13); infusion-end: control 74 ± 5 (P = 0.007), buprenorphine 53 ± 5 (P > 0.98). Respiratory rate (breaths per minute): baseline: control 17 vs buprenorphine 14 (P = 0.03); infusion-end: control 15 (P = 0.09), buprenorphine 12 (P < 0.01). Infusion-end plasma morphine concentrations (ng/mL): control 23 ± 1, buprenorphine 136 ± 10. Conclusions Buprenorphine subjects, compared with controls, were hyperalgesic (cold pressor test), did not experience antinociception, despite high plasma morphine concentrations, and experienced respiratory depression. Clinical implications are discussed.
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Affiliation(s)
- Peter Athanasos
- Discipline of Psychiatry, Flinders University, Bedford Park, Australia
| | - Walter Ling
- Integrated Substance Abuse Programs, University of California, Los Angeles, California, USA
| | - Felix Bochner
- Discipline of Pharmacology, Faculty of Health and Medical Sciences, University of Adelaide, Adelaide, Australia.,Department of Clinical Pharmacology, Royal Adelaide Hospital, Adelaide, Australia
| | - Jason M White
- School of Pharmacy and Medical Sciences, University of South Australia, Adelaide, Australia
| | - Andrew A Somogyi
- Discipline of Pharmacology, Faculty of Health and Medical Sciences, University of Adelaide, Adelaide, Australia.,Department of Clinical Pharmacology, Royal Adelaide Hospital, Adelaide, Australia
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Lembke A, Ottestad E, Schmiesing C. Patients Maintained on Buprenorphine for Opioid Use Disorder Should Continue Buprenorphine Through the Perioperative Period. PAIN MEDICINE 2019; 20:425-428. [PMID: 29452378 PMCID: PMC6387981 DOI: 10.1093/pm/pny019] [Citation(s) in RCA: 41] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Affiliation(s)
- Anna Lembke
- Departments of Psychiatry and Behavioral Sciences.,Anesthesiology, Perioperative and Pain Medicine, Stanford University School of Medicine, Stanford, California, USA
| | - Einar Ottestad
- Anesthesiology, Perioperative and Pain Medicine, Stanford University School of Medicine, Stanford, California, USA
| | - Cliff Schmiesing
- Anesthesiology, Perioperative and Pain Medicine, Stanford University School of Medicine, Stanford, California, USA
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Koller G, Schwarzer A, Halfter K, Soyka M. Pain management in opioid maintenance treatment. Expert Opin Pharmacother 2019; 20:1993-2005. [DOI: 10.1080/14656566.2019.1652270] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Affiliation(s)
- Gabi Koller
- Department of Psychiatry and Psychotherapy, University Hospital, LMU Munich, Munich, Germany
| | - Andreas Schwarzer
- Department of Pain Medicine, BG University Hospital Bergmannsheil, Ruhr University Bochum, Bochum, Germany
| | - Kathrin Halfter
- Institute for Medical Informatics, Biometry and Epidemiology, Ludwig-Maximilians-University München, Munich, Germany
| | - Michael Soyka
- Department of Psychiatry and Psychotherapy, University Hospital, LMU Munich, Munich, Germany
- Medical Park Chiemseeblick, Bernau, Germany
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Goel A, Azargive S, Weissman JS, Shanthanna H, Hanlon JG, Samman B, Dominicis M, Ladha KS, Lamba W, Duggan S, Di Renna T, Peng P, Wong C, Sinha A, Eipe N, Martell D, Intrater H, MacDougall P, Kwofie K, St-Jean M, Rashiq S, Van Camp K, Flamer D, Satok-Wolman M, Clarke H. Perioperative Pain and Addiction Interdisciplinary Network (PAIN) clinical practice advisory for perioperative management of buprenorphine: results of a modified Delphi process. Br J Anaesth 2019; 123:e333-e342. [PMID: 31153631 PMCID: PMC6676043 DOI: 10.1016/j.bja.2019.03.044] [Citation(s) in RCA: 33] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2018] [Revised: 03/09/2019] [Accepted: 03/21/2019] [Indexed: 01/09/2023] Open
Abstract
Until recently, the belief that adequate pain management was not achievable while patients remained on buprenorphine was the impetus for the perioperative discontinuation of buprenorphine. We aimed to use an expert consensus Delphi-based survey technique to 1) specify the need for perioperative guidelines in this context and 2) offer a set of recommendations for the perioperative management of these patients. The major recommendation of this practice advisory is to continue buprenorphine therapy in the perioperative period. It is rarely appropriate to reduce the buprenorphine dose irrespective of indication or formulation. If analgesia is inadequate after optimisation of adjunct analgesic therapies, we recommend initiating a full mu agonist while continuing buprenorphine at some dose. The panel believes that before operation, physicians must distinguish between buprenorphine use for chronic pain (weaning/conversion from long-term high-dose opioids) and opioid use disorder (OUD) as the primary indication for buprenorphine therapy. Patients should ideally be discharged on buprenorphine, although not necessarily at their preoperative dose. Depending on analgesic requirements, they may be discharged on a full mu agonist. Overall, long-term buprenorphine treatment retention and harm reduction must be considered during the perioperative period when OUD is a primary diagnosis. The authors recognise that inter-patient variability will require some individualisation of clinical practice advisories. Clinical practice advisories are largely based on lower classes of evidence (level 4, level 5). Further research is required in order to implement meaningful changes in practitioner behaviour for this patient group.
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Affiliation(s)
- Akash Goel
- Department of Anaesthesia, University of Toronto, Canada; T.H. Chan School of Public Health, Harvard University, USA
| | - Saam Azargive
- Department of Anaesthesia, University of Toronto, Canada; Department of Anaesthesia, Queen's University School of Medicine, Canada
| | - Joel S Weissman
- T.H. Chan School of Public Health, Harvard University, USA; Department of Surgery, Brigham and Women's Institute, USA
| | | | - John G Hanlon
- Department of Anaesthesia, University of Toronto, Canada
| | - Bana Samman
- Department of Anaesthesia, University of Toronto, Canada
| | - Mary Dominicis
- Department of Anaesthesia, University of Toronto, Canada
| | - Karim S Ladha
- Department of Anaesthesia, University of Toronto, Canada
| | - Wiplove Lamba
- Department of Psychiatry, University of Toronto, Canada
| | - Scott Duggan
- Department of Anaesthesia, Queen's University School of Medicine, Canada
| | - Tania Di Renna
- Department of Anaesthesia, University of Toronto, Canada
| | - Philip Peng
- Department of Anaesthesia, University of Toronto, Canada
| | - Clinton Wong
- Department of Anaesthesia, University of British Columbia, Canada
| | - Avinash Sinha
- Department of Anaesthesia, McGill University, Canada
| | - Naveen Eipe
- Department of Anaesthesia, University of Ottawa, Canada
| | - David Martell
- Department of Family Medicine, Dalhousie University, Canada
| | | | | | - Kwesi Kwofie
- Department of Anaesthesia, Dalhousie University, Canada
| | | | - Saifee Rashiq
- Department of Anaesthesia, University of Alberta, Canada
| | - Kari Van Camp
- Pain Research Unit, Toronto General Hospital, University of Toronto, Canada
| | - David Flamer
- Department of Anaesthesia, University of Toronto, Canada
| | | | - Hance Clarke
- Department of Anaesthesia, University of Toronto, Canada; Pain Research Unit, Toronto General Hospital, University of Toronto, Canada.
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50
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Goel A, Azargive S, Weissman JS, Shanthanna H, Ladha KS, Lamba W, Duggan S, Hanlon JG, Di Renna T, Peng P, Clarke H. Perioperative Pain and Addiction Interdisciplinary Network (PAIN): protocol of a practice advisory for the perioperative management of buprenorphine using a modified Delphi process. BMJ Open 2019; 9:e027374. [PMID: 31122990 PMCID: PMC6538090 DOI: 10.1136/bmjopen-2018-027374] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/09/2023] Open
Abstract
INTRODUCTION The ongoing opioid epidemic has necessitated increasing prescriptions of buprenorphine, which is an evidence-based treatment for opioid use disorder, and also shown to reduce harms associated with unsafe opioid administration. A systematic review of perioperative management strategies for patients taking buprenorphine concluded that there was little guidance for managing buprenorphine perioperatively. The aim of this project is to develop consensus guidelines on the optimal perioperative management strategies for this group of patients. In this paper, we present the design for a modified Delphi technique that will be used to gain consensus among patients and multidisciplinary experts in addiction, pain, community and perioperative medicine. METHODS AND ANALYSIS A national panel of experts identified by perioperative, pain and/or addiction systematic review authorship established an international profile in perioperative, pain and/or addiction research, community clinical excellence and by peer referral. A steering group will develop the first round with a list of indications to be rated by the panel of national experts, patients and allied healthcare professionals. In round 1, the expert panel will rate the appropriateness of each individual item and provide additional suggestions for revisions, additions or deletions. The definition of consensus will be set a priori. Consensus will be gauged for both appropriateness and inappropriateness of treatment strategies. Where an agreement is not reached and items are suggested for addition/deletion/modification, round 2 will take place over teleconference in order to obtain consensus. ETHICS AND DISSEMINATION Institutional research ethics board provided a waiver for this modified Delphi protocol. We plan on developing a national guideline for the management of patients taking buprenorphine in the perioperative period that will be generalisable across three sets of preoperative diagnoses including opioid use disorder and/or co-occurring pain disorders. The findings will be published in peer-reviewed publications and conference presentations.
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Affiliation(s)
- Akash Goel
- Department of Epidemiology, Harvard University T H Chan School of Public Health, Boston, Massachusetts, USA
- Department of Anesthesia, University of Toronto, Toronto, Ontario, Canada
| | - Saam Azargive
- Department of Anesthesiology and Perioperative Medicine, Queens University School of Medicine, Kingston, Ontario, Canada
| | - Joel S Weissman
- TH Chan School of Public Health, Harvard University, Boston, Massachusetts, USA
- Center for Surgery and Public Health, Brigham and Women’s Hospital, Boston, Massachusetts, USA
| | - Harsha Shanthanna
- Department of Anesthesia, McMaster University St Joseph’s Health Care, Hamilton, Ontario, Canada
| | - Karim S Ladha
- Department of Anesthesia, University of Toronto, Toronto, Ontario, Canada
- Pain Research Unit, Toronto General Hospital, University Health Network, Toronto, Ontario, Canada
| | - Wiplove Lamba
- Department of Psychiatry, University of Toronto, Toronto, Ontario, Canada
| | - Scott Duggan
- Department of Anesthesiology and Perioperative Medicine, Queens University School of Medicine, Kingston, Ontario, Canada
| | - John G Hanlon
- Department of Anesthesia, University of Toronto, Toronto, Ontario, Canada
| | - Tania Di Renna
- Department of Anesthesia, University of Toronto, Toronto, Ontario, Canada
- Toronto Academic Pain Medicine Institute, Women’s College Hospital, Toronto, Ontario, Canada
| | - Philip Peng
- Toronto Western Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Hance Clarke
- Pain Research Unit, Toronto General Hospital, University Health Network, Toronto, Ontario, Canada
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