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“Buprenorphine (Subutex) and the combination drug Suboxone in the Perianesthesia setting.”

Jennifer Nopoulos, MSNEd, RN, CPAN

Buprenorphine (Subutex), and the combination drug Suboxone are prescribed by providers that have gone through specific training to treat opioid addictions. This medication is available in sub-lingual tablets, buccal film, a long acting implant, or a 30-day sub-cutaneous injection (Strain, 2019).  The tablets and film are FDA approved for addiction treatment but are also used for chronic pain management (Burchum & Rosenthal, 2016). When patients on these drugs are scheduled for elective surgeries that are expected to cause moderate to severe pain, experts recommend some advanced planning to ensure adequate post-operative pain control (Bettinger, Fudin, & Argoff, 2017).

Unlike typical opioids that are full agonists, buprenorphine is a partial agonist-antagonist, stimulating some mu receptors and blocking kappa receptors (Burchum & Rosenthal, 2016; Bettinger, Fudin & Argoff, 2017). It provides greater pain relief than common opioids such as morphine with a decreased chance of respiratory depression, and therefore, less chance of lethal side effects. It is used for patients who have developed opioid tolerance from chronic opioid use, both prescribed and illicit. The combination drug Suboxone contains buprenorphine and naloxone, the purpose of the combination being to discourage abuse of the maintenance drug by users injecting it. If they do, the naloxone will block the opioid effect causing acute withdrawal and pain (Stain, 2019).

The drug has a long half-life, over two to three days. Due to its strong affinity for the mu receptor, it displaces full commonly used opioids and prevents binding and pain relief. Ideal pre-operative preparation is to taper and stop the buprenorphine over two-four weeks prior to the planned surgery. Another full opioid agonist can be prescribed to provide pain relief during this wash out time (Bettinger, Fudin, & Argoff, 2017).

Problems arise when surgery is urgent, or when the patient has not been instructed or has not complied with tapering instructions. Large doses of opioids would be required postoperatively and will be less effective than expected, with experts recommending fentanyl or hydromorphone as the best choices in this case.  Caution is advised regarding the cumulative effect of large doses of full opioid agonists. As buprenorphine levels drop, the chance of life-threatening respiratory depression increases. Hospitalization with monitoring is advised for three days after buprenorphine is stopped if the patient is receiving high doses of full opioid agonists (Bettinger, Fudin, & Argoff, 2017).

For best patient care, preoperative RNs and those that do pre-surgical screening must be aware of the unique challenges for pain management in patients that use buprenorphine or its combination preparations. Communication and care planning are essential with all caregivers: surgeon, anesthesia provider, patient, family, and post-operative (PACU) RNs.

Bettinger, J.J., Fudin, J.F., & Argoff, C. (2017, Sept). Buprenorphine and surgery: What's the protocol? In N. Keen (Ed), Opioid Prescribing and Monitoring (pp. 73-78). Vertical Health, LLC.

Burchum, J.R., & Rosenthal, L.D. (2016). Lehne’s pharmacology for nursing care (9th ed.). MO:   Elsevier.

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