A 28-year-old opioid-dependent patient on buprenorphine maintenance is admitted for a surgical procedure requiring post-operative analgesia. What is the CORRECT analgesic approach?
- A Stop buprenorphine 24 hours pre-operatively and use standard opioid analgesics
- B Switch to methadone 24 hours before surgery for better analgesic control
- C Continue buprenorphine and supplement with multimodal non-opioid analgesia; additional full-agonist opioids can be used at higher-than-usual doses if needed ✓
- D Give naloxone to reverse buprenorphine and start morphine infusion
Correct answer: C. Continue buprenorphine and supplement with multimodal non-opioid analgesia; additional full-agonist opioids can be used at higher-than-usual doses if needed
Explanation
Buprenorphine is a partial mu-opioid agonist with very high receptor affinity. Current guidelines (ASA, SAMHSA) recommend continuing buprenorphine perioperatively to prevent withdrawal and craving. Additional analgesia should use multimodal approaches (NSAIDs, ketamine, regional blocks). If full opioid agonists are required for severe pain, they can still bind at non-occupied receptors and provide analgesia, but higher doses may be needed due to competitive displacement. Abruptly stopping buprenorphine risks relapse and withdrawal.
Reference: Kaplan & Sadock's Synopsis of Psychiatry, 11th ed.
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