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PostPosted: Tue Jan 11, 2011 6:22 pm 
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Here's another paper/article about treating post-operative pain in bupe patients. This goes along nicely with the other article that discusses treating acute pain in sub patients.

Thanks to Dr. J for this!

Here's an excerpt from the paper:

Opioid-dependent patients are often treated with buprenorphine. Worldwide, opioid dependence has been on the increase in the last decade and many of these patients present for surgery and for postoperative pain control. In 1996, buprenorphine was available in France as a substitution treatment for heroin addicts. In the United States, the Food and Drug Administration approved buprenorphine to be marketed only in the form of sublingual tablets (Subutex) or with naloxone (Subuxone) to treat opioid dependence. The rescheduling of buprenorphine from a schedule V to a schedule III narcotic was published in the Federal Register in October, 2002. Methadone, also used for the treatment of opioid abuse, is a schedule II drug. Schedule II drugs have more abuse potential than schedule III drugs.

Postoperative pain control of patients on preoperative buprenorphine can be a challenge and can complicate postoperative pain management. The possibility that the tight binding with the mu receptor could lead to partial opioid blockade with resultant reduction in postoperative analgesia when treated with opioids has been raised as a point of concern. There is also concern for relapse in patients taking buprenorphine for opioid dependence, which may also complicate pain management in the postoperative period. This should be taken into consideration while caring for opioid-dependent
patients on buprenorphine in the postoperative period. The National Drug Abuse Treatment Clinical Trials Network Prescription Opioid Addiction Treatment Study, presented at the American Psychiatric Association annual meeting in 201042, showed that tapering with buprenorphine over 9 months led to almost universal relapse in persons
dependent on prescription opioids.

Reviews of literature include several studies on and management strategies for preoperative pain in patients who are on buprenorphine as maintenance therapy for drug abuse.
Alford and colleagues have recommended that patients be converted to full opioid agonist preoperatively. Roberts and Meyer-Witting suggest that buprenorphine be continued throughout the perioperative period and full agonist opioid be used for pain control when monitoring for respiratory depression and pain control. They also suggest that buprenorphine be discontinued up to 72 hours before the surgery and converted to a full agonist such as methadone to eliminate the existence of any partial blockade.

Ballantyne and La Forge recommend that buprenorphine be discontinued for about a week before surgery.
Several studies in contrast to this concept suggest that full opioid agonists are effective in buprenorphine-treated patients. Budd and Collett16 concluded that full opioid agonists are effective in acute and chronic pain syndromes in the presence
of buprenorphine use and that buprenorphine does not produce persistent blockade of the mu receptor. There are other reports that demonstrate the effective use of full opioid agonists such as morphine in patients treated with buprenorphine and that buprenorphine use can be continued into the postoperative period. Mitra and Sinatra46 recommend that patients on maintenance therapy take their morning dose of buprenorphine or methadone on the day of surgery to decrease the risk of opioid withdrawal during surgery.

Mehta and Langford recommend the use of short-acting full opioid agonists for postoperative pain control in patients using transdermal buprenorphine. Morphine has shown to be an effective breakthrough medication in patients on transdermal
buprenorphine. A study by Mercadante and colleagues48 of 29 cancer patients demonstrated the effectiveness of morphine for pain control as a breakthrough medication in patients receiving transdermal buprenorphine.

A study by Jones and colleagues done on obstetric patients also demonstrated the successful use of opioid agonists in the presence of buprenorphine maintenance. Finally, buprenorphine has been used effectively to control postoperative pain in
buprenorphine-maintained patients. Budd and Collett suggest that sublingual buprenorphine could be used effectively as a breakthrough agent to control pain in patients on buprenorphine in the postoperative period.

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Fond Du Lac Psychiatry
Dr. Jeffrey Junig, M.D., Ph.D.

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