Opioids

Question 1

Why is careful planning of the periop management of suboxone so important? What’s the best approach?

Answer 1

buprenorphine has the highest affinity to the mu receptor of any other clinically-used opioid yet is has low intrinsic activity & it’s also an antagonist at the kappa opioid receptor. It can block other opioid effects & may cause withdrawal if started inappropriately.
Unclear evidence for the best approach but continue pts usual buprenorphine perioperatively, anticipating that in the presence of buprenorphine higher than normal doses of a full mu agonist will be required for pain control.
In the rare case that the pt can’t take their usual sublingual or buccal buprenorphine, administer it IV, reducing daily dose by 50% & dividing it into 3 equal doses administered 8-hourly.
Use non-pharmacologic & non-opioid pharmacologic analgesia before adding opioids.

Question 2

What’s considered a high dose of suboxone that would interfere with intra- or post-op opioid therapy?

Answer 2

8mg equivalent of suboxone/subutex

Question 3

How long does a dose of buprenorphine or methadone last?

Answer 3

6-8hrs

Question 4

What’s the problem of periop management of pts taking naltrexone?

Answer 4

It blocks the effects of opioid agonists so acute pain management particularly challenging

Question 5

Why is buprenorphine/naloxone not recommended in severe liver impairment?

Answer 5

naloxone has increased bioavailability so the combo may be ineffective

Question 6

What are some benefits of buprenorphine?

Answer 6

causes less hyperalgesia, euphoria & psychologic reward than other opioids, produces less resp depression & has a ceiling effect for resp depression but not for analgesia @ clinically meaningful doses.