An expert panel comprising members from several pain-related medical and pharmacological societies has developed new recommendations for the perioperative management of pain in patients being treated for opioid use disorder (OUD).1

Board directors from the American Society of Regional Anesthesia and Pain Medicine, American Society of Anesthesiologists, American Academy of Pain Medicine, American Society of Addiction Medicine, and American Society of Health System Pharmacists approved the creation of the Multisociety Working Group on Opioid Use Disorder, representing the fields of pain medicine, addiction, and pharmacy health sciences.

In the United States, OUD is at an all-time high. Medication for OUD (MOUD) is effective, but barriers to access include lack of education, insurance hurdles, and general distaste for patients so afflicted.

Optimal analgesia can be obtained in patients with MOUD perioperatively. Pain management care givers can recommend and consider initiating MOUD in patients with suspected OUD at the point of care and serve as a bridge to comprehensive treatment, improve patient outcome and ultimately save lives.

Members of the Multisociety Working Group conducted an in-depth literature search including multiple study types. They reviewed the studies for quality, employing a modified Delphi process to assess the literature and expert opinion for each topic, with 100% consensus being achieved on the statements and each recommendation.

Committee members graded consensus statements using the United States Preventive Services Task Force grading of evidence guidelines. They performed a narrative overview of buprenorphine, including pharmacology and legal statutes. Two core topics were identified for the development of recommendations with 100% consensus reached on both topics.

Specific topics included: 1) providing recommendations to aid physicians in the management of patients receiving buprenorphine for MOUD in the perioperative setting; and 2) providing recommendations to aid physicians in the initiation of buprenorphine in patients with suspected OUD in the perioperative setting.

The working group concluded that, to decrease the risk of OUD recurrence, buprenorphine should not be discontinued routinely in the perioperative setting. Buprenorphine can be initiated in untreated patients with OUD and acute pain perioperatively to decrease the risk of OUD recurrence and death from overdose.

The Working Group Recommendations for Perioperative Management of a Patient on Buprenorphine for OUD1 are available for free download in its entirety.

Here are some of the recommendations:

* Preoperative planning (Grade B, Moderate Level of Certainty):

1. Buprenorphine should not be routinely discontinued preoperatively.

2. Discontinuing buprenorphine can increase risk of OUR or harm.

3. In most cases, avoid tapering buprenorphine prior to surgery Intraoperatively

* Intraoperative and postoperative Planning (Grade B, Moderate Level of Certainty):

1. Multimodal analgesia, including adjunctive medications and regional techniques should be utilized whenever possible.

2. Consider administration of full mu agonists with high affinity for the mu receptor if needed to achieve adequate analgesia.(Grade C, Low level of Certainty):

3. Consider increasing and/or dividing dosing of buprenorphine to achieve adequate analgesia.

* Discharge planning (Grade A, moderate level of certainty):

1. If a full mu agonist is initiated or if buprenorphine is increased during the perioperative period, a post-discharge plan to taper off the full mu agonist or return to the preoperative dose of buprenorphine is recommended.

2. Engage in collaboration with the patient's outpatient buprenorphine prescriber if possible.

* Perioperative management of a patient with an untreated, active OUD (Grade B, moderate level of certainty):

1. Consider starting buprenorphine for postoperative analgesia in patients with suspected OUD, utilizing available social work or ancillary services to help facilitate linkage to outpatient buprenorphine prescribers when possible. (Grade C, low level of certainty):

2. Buprenorphine treatment can still be considered in circumstances in which follow-up/insurance coverage has not been fully established.

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