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Perioperative Management of Buprenorphine/Naloxone in a Large, National Health Care System: a Retrospective Cohort Study

Abstract

Background

Medication for opioid use disorder, including buprenorphine and methadone, is considered the gold standard treatment for opioid use disorder (OUD). As the number of patients receiving buprenorphine has grown, clinicians increasingly care for patients prescribed buprenorphine who present for surgery and require management of perioperative pain.

Objective

To describe practice patterns of perioperative and post-surgical use of buprenorphine among patients prescribed buprenorphine for OUD who experience major surgery.

Design

Retrospective cohort study utilizing data from the VA Corporate Data Warehouse (CDW), a national repository of patient-level data. Data not accessible in CDW, including clinical instructions to patients to modify buprenorphine dose, were accessed via chart review.

Participants

National sample of patients receiving care through the Veterans Health Administration.

Main Measures

We report descriptive statistics on the incidence of buprenorphine dose hold prior to, during, and immediately following surgery, as well as post-surgical outcomes. Multivariable logistic regression identified socio-demographic and clinical characteristics associated with perioperative hold.

Key Results

Our final sample comprised 183 patients, the majority of whom were white and male. Most patients (66%) experienced a perioperative buprenorphine dose hold: during the pre-operative, day of surgery, and post-operative periods, 40%, 62%, and 55% of patients had buprenorphine held. Buprenorphine dose hold was less likely for patients who had experienced homelessness/housing insecurity in the year prior to surgery (aOR = 0.25; 95% CI 0.10–0.61) as well as patients residing in rural areas (aOR=0.29; 0.12–0.68). Within the 12-month period following surgery, 122 patients (67%) were retained on buprenorphine, 10 patients (5.5%) had experienced an overdose, and 15 (8.2%) had died.

Conclusions

We identified high rates of perioperative buprenorphine dose holds. As holding buprenorphine perioperatively does not align with emerging clinical recommendations and carries significant risks, educational campaigns or other provider-targeted interventions may be needed to ensure patients with OUD receive recommended care.

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Funding

This work was supported by a VA CIVIC Pilot Award, VA HSR&D Center of Innovation, Career Development Award (IK2HX003007) from the US Department of Veterans Affairs Health Services Research and Development, and resources from the VA Health Services Research and Development–funded Center to Improve Veteran Involvement in Care at the VA Portland Health Care System (CIN 13-404). This work was also supported by F30 DA044700 (KP) from the National Institute on Drug Abuse (NIDA). The views expressed in this article are those of the authors and do not necessarily reflect the position or policy of the Department of Veterans Affairs or the United States government.

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Correspondence to Jessica J. Wyse PhD.

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Wyse, J.J., Herreid-O’Neill, A., Dougherty, J. et al. Perioperative Management of Buprenorphine/Naloxone in a Large, National Health Care System: a Retrospective Cohort Study. J GEN INTERN MED (2021). https://doi.org/10.1007/s11606-021-07118-4

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KEY WORDS

  • buprenorphine
  • perioperative period
  • opioid-related disorders
  • Veterans health