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?
Title: Pain Management in Patients on Buprenorphine-Naloxone: A Comprehensive Approach
Introduction
The case of a 27-year-old woman admitted to the hospital with a perforated gastric ulcer while on buprenorphine-naloxone (Suboxone®) for opioid dependence presents a challenging scenario in terms of pain management. Patients who are taking buprenorphine-naloxone require careful consideration and adjustments in their medication regimen to effectively manage acute pain while minimizing the risk of opioid overdose and withdrawal symptoms.
Pain Management in Patients on Buprenorphine-Naloxone
Buprenorphine-naloxone is a combination medication used for medication-assisted treatment (MAT) of opioid dependence. Buprenorphine is a partial opioid agonist with a high affinity for the mu-opioid receptors, while naloxone is included to deter misuse. It is important to recognize that buprenorphine has a unique pharmacological profile that affects pain management strategies in patients on this medication.
- Preoperative Assessment:
Before undergoing any surgery, a comprehensive assessment of the patient’s opioid dependence, buprenorphine-naloxone dosage, and pain management plan should be conducted. It is crucial to know the patient’s daily dose (in this case, 16 mg) and the timing of their last dose (20 hours prior to surgery).
- Intraoperative Management:
In the preoperative phase, patients may receive short-acting opioids, such as hydromorphone, to manage acute pain. This choice of medication is appropriate due to its strong analgesic effects, which can effectively alleviate pain in surgical emergencies. However, physicians should exercise caution and closely monitor the patient’s response to opioids to avoid over-sedation or respiratory depression.
- Postoperative Pain Management:
After surgery, the patient is placed on a patient-controlled analgesic (PCA) pump containing fentanyl. Here, it is essential to address pain effectively while considering the patient’s buprenorphine-naloxone treatment.
a. Assess the Adequacy of Analgesia:
- Frequent pain assessments are necessary to ensure that the patient’s pain is adequately managed. The PCA pump can provide a controlled dose of fentanyl, but it should be titrated to the patient’s pain level to avoid under- or over-medication.
b. Adjusting the Buprenorphine-Naloxone Regimen:
- The buprenorphine-naloxone dosage may need to be temporarily increased or adjusted during the postoperative period to manage acute pain adequately. This should be done in collaboration with an addiction medicine specialist or a pain management team.
- The timing of the last buprenorphine-naloxone dose is critical. If the patient’s last dose was more than 24 hours prior to surgery, their risk of experiencing precipitated withdrawal symptoms is lower, and opioid analgesics can be more readily introduced.
c. Monitor for Opioid Overdose:
- Continuous monitoring for signs of opioid overdose, such as respiratory depression and sedation, is essential when using opioids concurrently with buprenorphine-naloxone.
d. Naloxone Availability:
- Naloxone should be readily available to reverse opioid overdose if necessary. This is particularly crucial when patients are receiving opioids postoperatively.
- Transition to Buprenorphine-Naloxone:
Once the patient’s acute pain is under control and they are stable, a transition plan to resume buprenorphine-naloxone should be implemented. The patient’s dosage may need to be adjusted based on the increased opioid tolerance developed during the hospital stay.
Conclusion
Managing pain in patients taking buprenorphine-naloxone requires a thoughtful and tailored approach. In the case of our 27-year-old patient with a perforated gastric ulcer, the use of hydromorphone in the ED and fentanyl on a PCA pump was appropriate for managing acute pain. Close monitoring for opioid overdose, adjustment of the buprenorphine-naloxone regimen, and timely transition back to maintenance therapy are crucial steps to ensure both effective pain management and continued treatment of opioid dependence. Collaboration between surgical, addiction medicine, and pain management teams is essential to provide comprehensive care for such patients