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I encourage clinicians to engage ii studies to validate a stepwise approach to treating surgical patients that have active prescriptions for buprenorphine.
For now however, the bottom line is…USE COMMON SENSE!
[AOT examples include morphine, oxycodone, hydrocodone, hydromorphone, fentanyl, and others.] One of the most misunderstood opioids among clinicians is buprenorphine, and even more especially when combined with naloxone in the branded form of Suboxone®.
If a patient has a scheduled or elective surgery with an active prescription for any buprenorphine product, the approach is not too difficult, but it requires an understanding of pharmacology, rational polypharmacy, but most importantly, common sense.
Certain literature (available upon request) misinterprets previously published recommendations and makes the leap that methadone 30-40mg/day could be used in the acute surgery setting to replace buprenorphine. The methadone could stay around for quite some time (half-life of 10-60 hours)…just enough time to cause significant toxicity as the buprenorphine wears off.
Others say use hydromorphone by continuous IV infusion.
Or, I have seen scenarios where the patient is sent home with oxycodone, hydrocodone, morphine, or others, and told to resume their buprenorphine…and the patient wonders why their pain isn’t controlled.
Envision trying to treat that severe pain with acute opioid therapy (AOT) but that with each sequential dose escalation, your attempts remain futile because naloxone is blocking the AOT from combining at the site of action, the mu-2 opioid receptors.Even the manufacturer (Reckitt Benckiser) admits to this, as seen in a 2004 Johns Hopkins University School of Medicine writing entitled “Practical Considerations for the Clinical Use of Buprenorphine“.How then did Reckitt Benckiser ever convince the FDA that this is a necessary or safer combination compared to buprenorphine alone? Jones shares a diagram that is ironically referenced to the eminent Suboxone manufacturer, Reckitt Benckiser.PLEASE tell us how you handle these patients if you are a clinician.For patients, we sure would be interested to learn of your surgical experiences.