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Î MAJOR REVISION – The addition of a short-acting full agonist opioid
to the patient's regular dose of buprenorphine can be effective for
the management of severe acute pain in supervised settings, such as
during hospitalization.
• The dose of additional full agonist opioid analgesic prescribed is anticipated to be
higher than the typical dose necessary to achieve adequate analgesia in opioid-
naïve individuals.
• Because of a lack of evidence, the committee was unable to come to consensus
on whether this adjunct treatment can be safely prescribed in ambulatory care
settings.
Î MAJOR REVISION – Discontinuation of methadone or buprenorphine
before surgery is NOT required.
• Higher-potency intravenous full agonist opioids can be used perioperatively for
analgesia.
Î Decisions related to discontinuing or adjusting the dose of
buprenorphine prior to a planned surgery should be made on an
individual basis through consultation between the surgical and
anesthesia teams and the addiction treatment provider when possible.
Î MAJOR REVISION – If it is decided that buprenorphine or methadone
should be discontinued before a planned surgery, this may occur the
day before or the day of surgery, based on surgical and anesthesia
team recommendations.
• Higher-potency intravenous full agonist opioids can be used perioperatively for
analgesia.
• Methadone or buprenorphine can be resumed post-operatively when the need for
full opioid agonist analgesia has resolved, with additional considerations for post-
operative pain management as described for acute pain above.
• The initial dose and titration should typically be determined by the prescriber.
• In general, pre-surgery daily doses of these medications can be resumed if they
were withheld for less than 2–3 days.
Î Patients on naltrexone may not respond to opioid analgesics in the
usual manner. Therefore, it is recommended that mild pain be treated
with non-opioid analgesics, and moderate to severe pain be treated
with higher potency NSAIDs (e.g., ketorolac) on a short-term basis.
Î Oral naltrexone should be discontinued 72 hours before surgery and
extended-release injectable naltrexone should be discontinued 30
days before an anticipated surgery. (Reinitiation of naltrexone should
follow the guidance on p. 12 of this pocket guide.)
Î NEW – Naltrexone's blockade of the mu opioid receptor can often be
overcome when necessary with high potency full agonist opioids.
• In these instances, patients should be closely monitored in an emergency
department or hospital setting.
