Perioperative Management of the Surgical Patient on Suboxone (Buprenorphine and Naloxone)

Over the past two decades, the incidence of legal and illegal drug abuse and dependency has increased at alarming levels, resulting in a rise in the number of associated deaths. Multiple resources are available to manage addiction, including the use of buprenorphine with or without naloxone. Consequently, more and more patients are requiring this treatment and are presenting for elective and emergent surgery where treatment of acute postoperative pain in the setting of buprenorphine use becomes challenging due to its unique properties. Buprenorphine has unique properties in which it binds to the opioid (mu) receptor with a higher affinity than other opioids. Buprenorphine is bound for a long period of time (32 hours), but its opioid effects have a ceiling. Since the receptors are occupied, when illegal or prescribed opioids are abused, they cannot activate the occupied receptors, and, in parallel, the effects that lead to addiction, tolerance, and craving are limited. However, in the surgical setting, increased opioid use may be appropriately needed to manage pain, which is hindered and limited by buprenorphine. Using current studies and strategies, we propose an algorithm to effectively manage buprenorphine in the perioperative setting.