DECEMBER 13, 2022
ON PAIN: Confusion on MOUD Use and Surgery ‘Pervasive’
How do you provide adequate pain control for a patient taking a medication for opioid use disorder (MOUD) who is about to undergo surgery?
You might keep the patient on their MOUD, according to experts.
But that’s not historically what’s been done. In this interview for ON PAIN, Antje Barreveld, MD, a co-author of 2021’s multisociety recommendations on buprenorphine use in the perioperative period, explains the importance of obtaining the knowledge on how patients with OUD or substance use disorders can continue certain MOUD—receiving adequate pain control but also reducing the risk for future overdose and death from OUD.
One experience in particular came to mind, Barreveld, the medical director of pain management services and co-founder and director of education and outreach for substance use services at Newton-Wellesley Hospital, in Newton, Mass., and an assistant professor of anesthesiology at Tufts University School of Medicine, in Boston, told Pain Medicine News. She was treating a patient with a substance use disorder and acute appendicitis, a combination that spelled an unclear treatment path for many of her colleagues. “The confusion around how to manage his pain was so pervasive throughout his hospitalization [that] he himself also felt stigmatized for being someone who is in recovery,” she said. “And there were misconceptions about how to use opioids for someone with a history of alcohol use disorder who’s also on an opioid antagonist or a blocker.
“So, that was an opportunity where we realized we really need to do a better job of educating our staff and making patients feel like substance use is a treatable disease and one that we care about and can do something about, and that pain management is possible in patients with a substance use disorder.”
Watch more videos in the series, and other content, at PainMedicineNews.com/Multimedia.
Meaghan Lee Callaghan 00:00
I do want to start off with a really easy question. Could you tell me your name and however you want to identify yourself?
Antje Barreveld, MD 00:19
Absolutely. My name is Dr. Antje Barneveld, and I am an anesthesiologist and the medical director for our pain management services at my hospital at Newton-Wellesley Hospital, in Newton, Massachusetts.
Callaghan 00:32
Very cool. I don’t even know where to start off. I had originally asked you so many questions about addiction, opioid use disorder, specifically, but you know, substance use disorder. And then I kind of found out you were involved with this working group that came up with this paper. Could you tell me a little bit about how that came to be?
Barreveld 00:53
Yes, I think one of the things I have seen as an anesthesiologist and pain management specialist is that we do not have enough access to care for patients with substance use disorders. And so what happened with this working group is our goal really has been to raise awareness around how we can care for patients with substance use, and make it feel less like this is a specialty that you have to have an addiction medicine specialty in order to be able to support our patients with opioid use disorder and other substance use needs. And our goal, again, really is around raising awareness and how we can work together to be able to support our patients, especially during the perioperative period.
Callaghan 01:37
Now, could you talk a little bit about your experience specifically in the hospital?
Barreveld 01:41
So, substance use touches every aspect of our community and, indeed, also our patients. What we sometimes don’t do is ask the right questions, so we don’t identify the patients that need help. And sometimes we really, as providers, don’t entirely understand what we’re supposed to do. There’s a lot of misconceptions about how we care for patients with substance use and how we get them safely through a hospitalization and surgery. And I can remember a patient of mine who had acute appendicitis, who was admitted to the hospital. He’s treated with naltrexone for alcohol use disorder, and the confusion around how to manage his pain was so pervasive throughout his hospitalization [that] he himself also felt stigmatized for being someone who is in recovery. And there were misconceptions about how to use opioids for someone with a history of alcohol use disorder, who’s also on an opioid antagonist or a blocker. So, that was an opportunity where we realized we really need to do a better job of educating our staff and making patients feel like substance use is a treatable disease and one that we care about and can do something about, and that pain management is possible in patients with a substance use disorder.
Callaghan 03:17
Moving back to the paper, do you think you could just summarize a little bit what the two main findings you guys came up with?
Barreveld 03:26
I think the main findings really were based off of the fact that we had this phenomenal group of experts in the fields of addiction medicine, pain management [and] anesthesiology realize that there are these misconceptions about how we manage patients on buprenorphine, and those that are going for surgery—whether it’s emergency surgery or elective surgery—and that it really is our job as stewards of pain management and stewards of safe opioid prescribing to understand exactly what to do with buprenorphine, and that this isn’t such a mysterious drug. This is an opioid that can also provide excellent pain control. So, I would say that our top two priorities were really to, again, decrease the stigma around opioid use disorder treatments in the perioperative setting, as well as to provide education tools for our providers to be able to treat our patients with opioid use disorder who are going for surgery and help them to access care in our communities.
Callaghan 04:32
So, what I kind of got from the paper was, if someone’s on buprenorphine, they should stay on it.
Barreveld 04:40
Absolutely.
Callaghan 04:41
And maybe you might even prescribe it perioperatively, if something comes up that maybe you think it’s needed. Is that right?
Barreveld 04:49
Yes, yes. And I think that we have too many examples of patients who stopped their buprenorphine around surgery and unfortunately had a setback. And the risks of an overdose [if the patient is] off of buprenorphine and death are really very high. And it still is in the community and in some of the other addiction fields that people think that you do need to stop it so that you can have adequate pain control. We know that we’re lacking robust studies that really look at pain control in patients on buprenorphine. However, we cannot forget that this is an opioid; this can be used, and there’s this confusion around the pharmacology of buprenorphine and mixed agonist–antagonist properties, and that managing pain, in general, in someone with a history of an opioid use disorder with opioids is very difficult. However, that does not mean that we should be stopping the medication or necessarily reflexively reducing the dose. That puts our patients at high risk. In particular, for surgeries where that’s absolutely not necessary. There are instances where a very painful surgery may ... we may anticipate additional needs in regards to opioids. And perhaps some dose adjustments could be indicated for an individual, but this needs to be a joint decision with the patient, the anesthesiologist, as well as the surgeon and the buprenorphine prescriber. So, it is not a simple one-size-fits-all [solution]. But let’s all step back and realize that we could put our patients at risk for overdose and death if we continue to do the practices that have been done historically, around stopping buprenorphine or decreasing the dose before surgery. So, we absolutely do not recommend doing this for all of our patients.
—PMN Staff