1. 2018;21;E1-E12Buprenorphine Formulations: Clinical Best Practice Strategies Recommendations for Perioperative Management of Patients Undergoing Surgical or Interventional Pain Procedures
   Guidelines
   Richard D. Urman, MD, Adrian B. Jonan, MD, and Alan D. Kaye, MD, PhD.

BACKGROUND: Starting with approval for clinical use in the treatment of opioid dependence in October 2002 by the Food and Drug Administration (FDA), buprenorphine has become an integral treatment option and in recent years, in chronic pain management. Buprenorphine possesses a unique pharmacodynamic and pharmacokinetic profile that can potentially make perioperative analgesia challenging. 

OBJECTIVES: To date no unified guidelines or recommendations are available for buprenorphine product management during the perioperative period. The present investigation aims to review the literature and provide recommendations when encountering a patient on buprenorphine therapy who is scheduled for a surgical or interventional pain procedure.

METHODS: Clinical studies and reviews were searched using the PubMed National Center for Biotechnology Information database using MeSH terms buprenorphine, buprenorphine and naloxone, suboxone, perioperative, and postoperative pain.

RESULTS: PubMed National Center for Biotechnology Information database search resulted in one randomized control trial, one prospective case matched cohort, one retrospective cohort, 0 case series, 4 case reports, and 6 review articles. Key literature is reviewed and summarized.

LIMITATIONS: Only 12 articles were included, which permits only limited recommendations drawn from this review.

CONCLUSIONS: The perioperative management of buprenorphine and buprenorphine/naloxone are dependent on several key factors. The nature of the surgery, namely the postoperative opioid requirement, elective versus emergency surgery, patient characteristics, formulation of buprenorphine, and indication for buprenorphine or buprenorphine/naloxone therapy must be considered when devising a plan. Several options exist when formulating a plan for the perioperative management, including continuing buprenorphine therapy or holding buprenorphine therapy for a defined period of time with or without bridging to alternative opioids. Additionally, social support people and patient motivation should be addressed and optimized, as well as nonopioid adjuvant therapy should be maximized as applicable to each patient undergoing a surgical or interventional pain procedure.

KEY WORDS: Buprenorphine, naloxone, surgery, pain management, anesthesia, suboxone, opioid abuse