. 2020 Aug 21;35(12):3635–3643. doi: 10.1007/s11606-020-06115-3

Table 3.

Recommendations for Acute Pain and Perioperative Management of Patients on Buprenorphine

Recommended management of buprenorphine	Recommended management of acute breakthrough pain	Discharge planning
Continue buprenorphine without dose reduction, including the following: • On morning of a planned surgery or procedure (whether minor or major) • During the postoperative period • During periods of acute, non-operative pain	Mild pain (pain scores 4 or less) or minor procedure (e.g., case 1): 1) Start with non-opioid analgesics (e.g., NSAIDs, acetaminophen). 2) Consider splitting buprenorphine dose into Q6-8h dosing; can increase total daily dose up to 32 mg for better pain coverage.* Moderate to severe pain (5 or more) or major procedure (e.g., case 2): In addition to recommendations for mild pain above, 1) If needed, add one short-acting full agonist opioid (e.g., oxycodone or hydromorphone) for breakthrough pain. Given underlying tolerance, higher doses will be required compared with opioid-naive patients (e.g., oxycodone 15–20 mg PO instead of 5–10 mg). Pain control should be reassessed after every dose. 2) IV opioids or PCAs without basal component (buprenorphine will play role of basal rate) may be considered in addition to patient’s buprenorphine if pain is not adequately controlled or if patient is not tolerating POs. 3) Regional blocks and non-opioid analgesia should also be encouraged.	Patient’s outpatient buprenorphine prescriber should be contacted prior to discharge to notify them of opioids received while in hospital and to arrange for follow-up appointment and should be informed of any doses changes and if patient will be discharged on additional opioids for pain. An X-waivered buprenorphine prescriber will need to write a discharge prescription to bridge to their next outpatient appointment.

Recommended management of buprenorphine

Recommended management of acute breakthrough pain

Discharge planning

Continue buprenorphine without dose reduction, including the following:

• On morning of a planned surgery or procedure (whether minor or major)

• During the postoperative period

• During periods of acute, non-operative pain

Mild pain (pain scores 4 or less) or minor procedure (e.g., case 1):

1) Start with non-opioid analgesics (e.g., NSAIDs, acetaminophen).

2) Consider splitting buprenorphine dose into Q6-8h dosing; can increase total daily dose up to 32 mg for better pain coverage.*

Moderate to severe pain (5 or more) or major procedure (e.g., case 2):

In addition to recommendations for mild pain above,

1) If needed, add one short-acting full agonist opioid (e.g., oxycodone or hydromorphone) for breakthrough pain. Given underlying tolerance, higher doses will be required compared with opioid-naive patients (e.g., oxycodone 15–20 mg PO instead of 5–10 mg). Pain control should be reassessed after every dose.

2) IV opioids or PCAs without basal component (buprenorphine will play role of basal rate) may be considered in addition to patient’s buprenorphine if pain is not adequately controlled or if patient is not tolerating POs.

3) Regional blocks and non-opioid analgesia should also be encouraged.

Patient’s outpatient buprenorphine prescriber should be contacted prior to discharge to notify them of opioids received while in hospital and to arrange for follow-up appointment and should be informed of any doses changes and if patient will be discharged on additional opioids for pain.

An X-waivered buprenorphine prescriber will need to write a discharge prescription to bridge to their next outpatient appointment.

*Some insurance companies do not approve outpatient doses of SL buprenorphine above 24 mg; however, it is FDA-approved up to 32 mg daily and can be increased to this dose while patient is inpatient