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The perioperative patient on buprenorphine: a systematic review of perioperative management strategies and patient outcomes

  • Akash Goel
  • Saam Azargive
  • Wiplove Lamba
  • Joel Bordman
  • Marina Englesakis
  • Sanjho Srikandarajah
  • Karim Ladha
  • Tania Di Renna
  • Harsha Shanthanna
  • Scott Duggan
  • Philip Peng
  • John Hanlon
  • Hance Clarke
Review Article/Brief Review

Abstract

Background

An increasing number of patients with opioid use disorder (OUD) are treated with opioid agonist-antagonists such as buprenorphine/naloxone. Perioperative management of patients on buprenorphine/naloxone is inconsistent and remains a controversial topic with mismanagement posing a significant risk to the long-term health of these patients.

Methods

We performed a systematic literature search involving Medline, Medline In-Process, Embase, Cochrane Central, Cochrane Database of Systematic Reviews, PsycINFO, Web of Science (Clarivate), Scopus (Elsevier), CINAHL (EbscoHosst), and PubMed (NLM).

Results

Eighteen studies were included in the final sample, including one controlled study and four observational studies . Neither the controlled study nor the observational studies assessed addiction treatment retention, harm reduction, or long-term mortality rates as primary or secondary outcomes. Of the observational studies, authors showed equivalent peri- and postoperative pain control among buprenorphine continued patients. All but one authors described adequate analgesia among the case reports in which buprenorphine ≤ 16 mg sublingually (SL) daily was continued during the perioperative period. Long-term harm reduction was not reported with only three case reports including any long-term abstinence or relapse rates.

Conclusions

The current understanding of the risks and benefits of continuing or stopping buprenorphine perioperatively is limited by a lack of high-quality evidence. Observational studies and case reports indicate no evidence against continuing buprenorphine perioperatively, especially when the dose is < 16 mg SL daily. In patients with significant potential for relapse, such as those with a recent history of OUD, the discontinuation of buprenorphine should have a strong rationale supported by patient and surgical preferences. Future studies require standardized reporting of median doses, details on the route of delivery, dosing schedules and any dosing changes, and rates of addiction relapse, including long-term morbidity and mortality where possible.

Le patient en période périopératoire sous buprénorphine : revue systématique des stratégies de gestion périopératoire et de l’évolution des patients

Résumé

Contexte

Un nombre croissant de patients présentant un trouble d’utilisation des opioïdes (TUO) sont traités avec des agonistes/antagonistes des opioïdes, tels que la buprénorphine et la naloxone. La gestion périopératoire des patients sous buprénorphine/naloxone n’est pas constante et reste un sujet de controverses; de plus une mauvaise gestion pose un risque significatif pour la santé à long terme de ces patients.

Méthodes

Nous avons effectué une recherche systématique de la littérature dans les bases de données suivantes : Medline, Medline In-Process, Embase, Cochrane Central, Cochrane Database of Systematic Reviews, PsycINFO, Web of Science (Clarivate), Scopus (Elsevier), CINAHL (EbscoHosst) et PubMed (NLM).

Résultats

Dix-huit études ont été incluses dans l’échantillon final, y compris une étude contrôlée et quatre études observationnelles. Ni l’étude contrôlée ni les études observationnelles n’ont évalué la continuation du traitement de l’addiction, la réduction des préjudices infligés ou les taux de mortalité à long terme parmi les critères d’évaluation principaux ou secondaires. Dans les études observationnelles, les auteurs ont montré qu’il y avait un contrôle équivalent de la douleur en péri- et postopératoire chez les patients continuant à recevoir de la buprénorphine. Tous les auteurs sauf un ont décrit une analgésie satisfaisante dans les rapports de cas où la buprénorphine sublinguale avec une dose ≤ 16 mg par jour était maintenue pendant la période périopératoire. La réduction des préjudices à long terme n’était pas décrite; seulement trois rapports de cas indiquaient le taux d’abstinence à long terme ou les taux de rechute.

Conclusions

Les connaissances actuelles des risques et avantages de la poursuite ou de l’arrêt de la buprénorphine en période périopératoire sont limitées par le manque de données probantes de grande qualité. Les études observationnelles et les rapports de cas ne fournissent pas de données probantes à l’encontre de la poursuite de la buprénorphine dans la période périopératoire, en particulier quand la dose journalière par voie sublinguale est < 16 mg. Chez les patients présentant un risque significatif de rechute, comme ceux ayant des antécédents récents de TUO, l’arrêt de la buprénorphine devrait être solidement justifié avec le soutien des préférences des patients et des équipes chirurgicales. Les futures études nécessitent une normalisation du rapport des doses médianes, des détails sur les voies d’administration, de la posologie et de sa modification et des taux de rechute, en incluant aussi, chaque fois que possible, les taux de morbidité et mortalité à long terme.

Notes

Conflicts of interest

Joel Bordman declares a conflict of interest with Purdue, Indivior, and Paladin Labs.

Editorial responsibility

This submission was handled by Dr. Gregory L. Bryson, Deputy Editor-in-Chief, Canadian Journal of Anesthesia.

Author contributions

Akash Goel, Saam Azargive, Marina Englisakis, and Hance Clarke formulated and devised the systematic review protocol. Akash Goel, Saam Azargive, John Hanlon, Harsha Shanthanna, Karim Ladha, and Wiplove Lamba assisted in writing the manuscript. Joel Bordman, Sanjho Srikandarajah, Scott Duggan, Tania Di Renna, and Philip Peng assisted in reviewing and editing the manuscript.

Funding statement

Support was provided solely from the institutional and/or departmental sources. Harsha Shanthanna is supported by the Canadian Anesthesia Research Foundation through the Career Scientist Award, 2018–2020.

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Copyright information

© Canadian Anesthesiologists' Society 2018

Authors and Affiliations

  • Akash Goel
    • 1
    • 2
  • Saam Azargive
    • 3
  • Wiplove Lamba
    • 4
  • Joel Bordman
    • 4
  • Marina Englesakis
    • 5
  • Sanjho Srikandarajah
    • 6
  • Karim Ladha
    • 1
    • 8
  • Tania Di Renna
    • 1
  • Harsha Shanthanna
    • 7
  • Scott Duggan
    • 3
  • Philip Peng
    • 1
  • John Hanlon
    • 1
  • Hance Clarke
    • 1
    • 8
  1. 1.Department of AnesthesiologyUniversity of TorontoTorontoCanada
  2. 2.T.H. Chan School of Public HealthHarvard UniversityCambridgeUSA
  3. 3.Department of Anesthesiology and Perioperative MedicineQueens University School of MedicineKingstonCanada
  4. 4.Department of PsychiatryUniversity of TorontoTorontoCanada
  5. 5.Library and Information ServicesToronto General HospitalTorontoCanada
  6. 6.Department of AnesthesiologyNorth York General HospitalNorth YorkCanada
  7. 7.Department of AnesthesiologyMcMaster UniversityHamiltonCanada
  8. 8.Pain Research Unit, Department of Anesthesia and Pain ManagementToronto General HospitalTorontoCanada

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