Managing in Patients who are Taking Buprenorphine-Naloxone
A 27-year-old woman on buprenorphine-naloxone (Suboxone®) for treatment of opioid dependence is admitted to the hospital with severe abdominal pain due to a perforated gastric ulcer. She received hydromorphone in the ED, and is urgently taken to the operating room. Postoperatively, she is on a patient-controlled analgesic (PCA) pump containing fentanyl. Her last dose of buprenorphine-naloxone was 20 h prior to the surgery; her daily dose is 16 mg.
Question: How can Pain be Managed in Patients who are Taking Buprenorphine-Naloxone? What Adjustments to her Medication Regimen can be Recommended?
Sample Solution
Analgesic management of patients taking buprenorphine-naloxone (Suboxone®) can be challenging given the risk of precipitated withdrawal, development of opioid tolerance and drug interactions. However, when managing pain in these patients it is important to consider their current opioid dose and duration of therapy as well as other medications they may be taking.
In this case, since the patient was already receiving a daily dose of 16 mg buprenorphine-naloxone 20 hours prior to her surgery, it is likely that she still has adequate levels in her system for effective pain control without additional doses or adjustments. Therefore, an acute-pain regimen involving an opioid such as fentanyl using a PCA pump should suffice for postoperative pain management. It would also be helpful to monitor the patient’s respiratory rate and sedation level closely following administration of opioids if needed due to potential decreased sensitivity to opioids at higher doses caused by chronic use of buprenorphine-naloxone.
Additionally, nonopioid analgesics such as acetaminophen or ibuprofen should also be considered since they have been shown to improve opioid efficacy during certain types of procedures when combined with opioids . Since these agents are not affected by CYP450 enzymes like buprenorphine is, there are no drug interactions between them and buprenorphine-naloxone that need to be taken into account for safety purposes. Furthermore, nonpharmacologic strategies such as distraction techniques or relaxation exercises could also help reduce her overall perception of pain if deemed appropriate based on clinical assessment.
It is important to recognize that due to its long half life, adjustment in dosage may not necessarily result in immediate effects from a pharmacodynamic standpoint; however reducing the dose while monitoring signs and symptoms suggestive of precipitated withdrawal can help avoid overmedication which can increase adverse events including respiratory depression associated with high doses or prolonged exposure times . Additionally counseling regarding proper disposal methods after cessation can decrease access leading abuse/misuse opportunities both by self and others.