John Bodnar, MS
Asif Ilyas, MD, MBA, FACS
Buprenorphine or methadone use in the perioperative period is challenging due to opioid tolerance, physical dependence, and the challenge of restarting treatment if discontinued
Current guidelines recommend continuing methadone or buprenorphine in the perioperative period for patients actively being treated for opioid use disorder
Chronic preoperative opioid consumption is associated with worse surgical outcomes in orthopedic surgery. There is currently insufficient evidence to conclude whether this holds true for treatment with methadone or buprenorphine.
Methadone (MMT) and buprenorphine (BUP) are long-acting mu-opioid receptor agonists commonly used to treat opioid use disorder (OUD). These two medications constitute a form of treatment for OUD called medication-assisted treatment (MAT). Surgeons may have concerns regarding the management of patients treated with these drugs in the perioperative setting .
Both MMT and BUP bind mu-opioid receptors with higher affinity compared to morphine, which raises the question of whether short-acting mu-opioid agonists such as morphine and hydrocodone typically utilized for orthopaedic surgery, can provide adequate postoperative analgesia . Surgeons must also weigh the risk of relapse into OUD that can be brought about by discontinuing MAT against the need to treat acute post-surgical pain management. Due to these challenges, advisory committees over the past two decades have made contradictory recommendations regarding the management of OUD patients needing surgery [1,2,3]. This analysis will focus on MMT and BUP specifically to review current recommendations regarding the use in the perioperative period, explore postoperative opioid use in patients receiving treatment prior to surgery, and discuss whether chronic use prior to orthopedic surgery increases the risk of post-surgical complications.
In 2004, the United States Center for Substance Abuse Treatment stated that BUP should be discontinued when patients are taking full mu-opioid agonist medications following a surgical procedure, such as oxycodone and hydrocodone . This advisory was based on poor evidence from a few case reports and led to the commonplace discontinuation of BUP prior to any surgery . In 2020, the American Society of Addiction Medicine (ASAM) stated that discontinuation of BUP before surgery should not be required. They also noted that when discontinuation is indicated, it should be done 24-36 hours prior to surgery, and subsequently restarted postoperatively as soon as possible, after the need for short-acting oral opioids has passed . The ASAM also stated that higher doses of short-acting opioids may be needed postoperatively to overcome tolerance and partial occupation of the mu-receptor by MMT .
Another argument for continuation comes from a 2019 study where 33.8% of patients who discontinued BUP in the perioperative period prior to elective orthopedic surgery had not resumed use within 90 days following the procedure (Figure 1) . This trend is
concerning as 50-90% of patients who discontinue MAT relapse . The study also found higher non-MAT opioid refill rates during the first 180 days following surgery in patients not restarted on BUP compared to those whose BUP was restarted . Another study found that patients who discontinued BUP consumed more morphine milligram equivalents (MME) in the 60 days following surgery compared to those who continued treatment in the perioperative period (Figure 2) . While the continuation of BUP in the immediate postoperative period is associated with decreased opioid consumption, the association with MMT is less clear (Figure 3) [6,7]. This is likely due to the analgesic properties of BUP reducing the need for other short-acting opioids.
Orthopedic surgeons should consider the association of preoperative MAT with surgical complications. Chronic opioid use has been shown to increase rates of surgical complications and decrease patient-reported outcomes across orthopedic specialties (8-10). Physiologic effects of chronic opioid consumption such as low testosterone increased fractures, and low bone mineral density may contribute to these outcomes [11,12]. Despite the biological plausibility, the view of preoperative opioid use as a marker of poor patient function and/or coping mechanisms leads to uncertainty as to the major contributor to these surgical complications. Further investigation is needed. Only one study has directly evaluated orthopedic surgical outcomes in patients treated with the BUP or MMT for OUD and found no difference in outcomes in the first year after total joint arthroplasty. However, this study was limited by its small sample of only 34 patients . Lack of strong evidence regarding how MMT or BUP affects outcomes in orthopedic surgery warrants additional research.
An increasing number of people are being treated with MAT as the medical community continues to battle the opioid epidemic. It is important that providers understand how to manage patients on BUP or MMT therapy in the perioperative setting. Additionally, providers should understand the rationale behind current guidelines and misconceptions regarding MAT. Since very little is known about how BUP and MMT affect outcomes in orthopedic surgery, future research on the effect of these medications in the operative setting could aid in assessing the risk versus benefit of surgery in these patients and provide insight into risk reduction.
Kohan L, Potru S, Barreveld AM, Sprintz M, Lane O, Aryal A, Emerick T, Dopp A, Chhay S, Viscusi E. Buprenorphine management in the perioperative period: educational review and recommendations from a multisociety expert panel. Reg Anesth Pain Med. 2021 Oct;46(10):840-859. doi: 10.1136/rapm-2021-103007.
Center for Substance Abuse Treatment Clinical Guidelines for the Use of Buprenorphine in the Treatment of Opioid Addiction. Treatment improvement protocol (tip) series 40. DHHS publication No. (SMA) 04-3939. Rockville, MD: Substance Abuse and Mental Health, 2004.
The ASAM National Practice Guideline for the Treatment of Opioid Use Disorder: 2020 Focused Update. J Addict Med. 2020 Mar/Apr;14(2S Suppl 1):1-91. doi: 10.1097/ADM.0000000000000633. Erratum in: J Addict Med. 2020 May/Jun;14(3):267.
Stone AB, Zhong H, Poeran J, Liu J, Cozowicz C, Illescas A, Memtsoudis SG. Trends in discontinuation of buprenorphine following elective orthopedic surgery: a national database analysis. Reg Anesth Pain Med. 2022 May 10:rapm-2022-103592. doi: 10.1136/rapm-2022-103592. Epub ahead of print.
Quaye A, Potter K, Roth S, Acampora G, Mao J, Zhang Y. Perioperative Continuation of Buprenorphine at Low-Moderate Doses Was Associated with Lower Postoperative Pain Scores and Decreased Outpatient Opioid Dispensing Compared with Buprenorphine Discontinuation. Pain Med. 2020 Sep 1;21(9):1955-1960. doi: 10.1093/pm/pnaa020.
Schuster B, Bell B, Massoll A, White S. Continuation Versus Discontinuation of Buprenorphine in the Perioperative Setting: A Retrospective Study. Cureus. 2022 Mar 22;14(3):e23385. doi: 10.7759/cureus.23385.
Macintyre PE, Russell RA, Usher KA, Gaughwin M, Huxtable CA. Pain relief and opioid requirements in the first 24 hours after surgery in patients taking buprenorphine and methadone opioid substitution therapy. Anaesth Intensive Care. 2013 Mar;41(2):222-30. doi: 10.1177/0310057X1304100212.
Hills JM, Pennings JS, Archer KR, Wick JB, Daryoush J, Butler M, Sivaganesan A, Khan I, Call R, Devin CJ. Preoperative Opioids and 1-year Patient-reported Outcomes After Spine Surgery. Spine (Phila Pa 1976). 2019 Jun 15;44(12):887-895. doi: 10.1097/BRS.0000000000002964.
Ridenour R, Kowalski C, Yadavalli A, Ba D, Liu G, Leslie D, Bible J, Aynardi M, Garner M, Dhawan A. Preoperative Opioid Use Is Associated With Persistent Use, Readmission and Postoperative Complications After Arthroscopic Knee Surgery. Arthroscopy. 2021 May;37(5):1567-1572. doi: 10.1016/j.arthro.2020.12.187. Epub 2020 Dec 16.
Xing B, Abd-Elsayed A. The Effect of Preoperative Opioid Dosage on Postoperative Outcomes in Patients Undergoing Knee Surgery. Pain Physician. 2020 Jan;23(1):73-85.
Jasuja GK, Ameli O, Reisman JI, Rose AJ, Miller DR, Berlowitz DR, Bhasin S. Health Outcomes Among Long-term Opioid Users With Testosterone Prescription in the Veterans Health Administration. JAMA Netw Open. 2019 Dec 2;2(12):e1917141. doi: 10.1001/jamanetworkopen.2019.17141.
Ramli FF, Syed Hashim SA, Mohd Effendy N. Factors Associated with Low Bone Density in Opioid Substitution Therapy Patients: A Systematic Review. Int J Med Sci. 2021 Jan 1;18(2):575-581. doi: 10.7150/ijms.52201.
Hansen LE, Stone GL, Matson CA, Tybor DJ, Pevear ME, Smith EL. Total Joint Arthroplasty in Patients Taking Methadone or Buprenorphine/Naloxone Preoperatively for Prior Heroin Addiction: A Prospective Matched Cohort Study. J Arthroplasty. 2016 Aug;31(8):1698-701. doi: 10.1016/j.arth.2016.01.032. Epub 2016 Jan 29.