NOVEMBER 30, 2022
ON PAIN: Why You Should Continue Patients on Buprenorphine Perioperatively
What happens when a patient who is prescribed buprenorphine undergoes surgery? Experts say they should continue the medication, predominantly prescribed for opioid use disorder, throughout the entire perioperative period. It doesn’t need to be stopped, Lynn Kohan, MD, the medical director of the Pain Management Center and an associate professor of anesthesiology at the University of Virginia, in Charlottesville, told Pain Medicine News. “You’re really putting patients at a greater risk by discontinuing it, and you really can control their pain if you continue it.”
Kohan spoke to us along with her colleagues Eugene Viscusi, MD, the director of the acute pain service and a professor of anesthesiology at Thomas Jefferson University, in Philadelphia, as well as a Pain Medicine News editorial advisory board member, and Sudheer Potru, MD, the medical director of the Atlanta VA’s multidisciplinary complex pain clinic and an assistant professor at Emory University, in Atlanta, for our video series ON PAIN. Part 1 of the full conversation is presented here, and parts 2 and 3 can be found at PainMedicineNews.com/Multimedia.
Sudheer Potru, MD 00:11
Hello. Hi, good evening. How are you?
Meaghan Lee Callaghan 00:14
I’m doing OK. How are you doing?
Potru 00:16
Good, thank you.
Callaghan 00:17
Could everyone really briefly say their name and however they’d want to identify themselves?
Potru 00:23
Sudheer Potru. I’m a triple board-certified anesthesiologist, pain specialist and addiction medicine specialist. I’m an assistant professor at Emory University in Atlanta.
Eugene Viscusi, MD 00:32
So, Gene Viscusi. I’m a professor of anesthesiology at Thomas Jefferson University in Philadelphia and the immediate past president of ASRA [the American Society of Regional Anesthesia and Pain Medicine].
Lynn Kohan, MD 00:40
I’m Lynn Kohan, associate professor of anesthesiology and pain medicine at the University of Virginia.
Callaghan 00:47
Yeah, so I am very interested with how you all—I mean, you were all co-authors, right, along with the societies? How did this kind of start? What was the genesis of this? I don’t know if, Gene, you want to start?
Viscusi 01:03
So, the start of this happened at this spring 2019 ASRA meeting. And he really challenged me and the society to think about what role anesthesiologists have in making an impact on the opioid crisis. And we talked a bit about how this is an opportunity, because so many of these patients come through the hospital setting with complications of their opioid use disorder, and that it really is a unique opportunity to capture these patients when they may be accepting of treatment, and when you have them for a few days. And I don’t think he was aware that many of us actually are working to initiate buprenorphine. So, he really challenged us to create some sort of initiative with ASA [the American Society of Anesthesiologists] and other societies that could provide guidelines for treatment or [rather] clinical recommendations for treatment.
Callaghan 01:28
Thank you, guys. It was in one of the emails; [it] kind of mentioned that maybe guidelines weren’t the proper way that you wanted to refer to it. Lynn, I see you nodding a lot. Could you maybe talk about that?
Kohan 02:42
It has to do with the fact that there’s multiple societies involved, which each kind of have different criteria for true guidelines. And so, it’s hard because it was this multi-society initiative to really establish guidelines. So, it’s really more recommendations. You know, there’s also not double-blinded, randomized controlled trials and things like that, that would also enhance the opportunity for it to be true guidelines. So, it’s really based on recommendations and guidance, education.
Potru 03:19
Yeah, I think that’s a really important point is that we just, we don’t have it ... you scour the anesthesia literature, the pain literature, the addiction literature. You ask experts in different fields, who don’t necessarily like cross fields, like some of us do, and I think you’ll get some differing opinions on how ... buprenorphine [and on] how these things should be managed, right? I’ve talked to some of my addiction colleagues about this, and they had been routinely even now in 2021, recommending that buprenorphine be stopped prior to surgery. It’s a very, very common thing in the addiction field, because they don’t necessarily have that perioperative experience, right, working in the operating room working on regional anesthesia and acute pain services, or working in pain clinics, right, where this is also somewhat of an issue as well.
Potru 04:10
And that was really kind of, for me, the most interesting thing about working with this particular group, this society, multi-society group, I should say. We had anesthesiologists; we have specialists in interventional pain; we have people who are board certified in addiction medicine, like myself, and who have interests kind of across all of these fields, who have a unique viewpoint, being able to see the insights that are coming from everywhere. And that’s, I think, really, really important in terms of analyzing this in terms of all the societies, right. And I think that was a really important part of us getting buy-in from the different societies, right, to make sure that we had the credibility and the backing of all these different very, very important organizations that are very critical to their fields in their own right to make sure that we have a certain level of authority to say the things that we said.
Kohan 04:59
And I think this is a little bit of a segue, but it brings up the important point. I think one of your questions was about are people stopping buprenorphine? And it’s still happening. I mean, even just with me. It was yesterday, I got a message from all the internal medicine docs about a patient. They’re just kind of still kind of insisting, “Well, but they’re having dental surgery. It’s going to be painful for two days.” [And I said,] “No, you don’t, you don’t need to stop.” And that’s why we felt it was really important to get this message out there because so many people really still believe in kind of the old literature that you couldn’t control pain with buprenorphine, and that it needed to be stopped. And that’s just not the case. You’re really putting patients at a greater risk by discontinuing it, and you really can control their pain if you continue it.
Viscusi 05:51
I think there’s still a huge misconception that buprenorphine is somehow an inferior analgesic. And the literature does not support that. The literature supports that it’s equivalent, at least equivalent to other opioids. And, you know, from that comes this idea that you’re somehow cheating the patient and they’re going to do more poorly. In reality, all you’re doing is putting the patient at risk; you’re not giving any advantage. And when you do discontinue, these patients consume typically large, large quantities of opioids, and then you have to deal with converting them back.
—PMN Staff