A patient on buprenorphine/naloxone (Suboxone) maintenance presents in acute pain after fracturing his femur. The anaesthesiologist asks about opioid management intraoperatively. The most appropriate intraoperative analgesia strategy is:
- A Continue buprenorphine perioperatively and supplement with full-dose opioids; higher opioid doses may be needed due to tolerance and partial agonism ✓
- B Stop buprenorphine 72 hours preoperatively and use full agonist opioids freely
- C Switch to methadone 24 hours before surgery for better opioid control
- D Use only NSAIDs as buprenorphine occupancy prevents opioid analgesic effect entirely
Correct answer: A. Continue buprenorphine perioperatively and supplement with full-dose opioids; higher opioid doses may be needed due to tolerance and partial agonism
Explanation
Current guidelines recommend continuing buprenorphine perioperatively to prevent relapse. Buprenorphine's high mu-opioid receptor affinity (partial agonist) means that additional full agonists will compete but cannot fully displace it; however, by increasing the dose of supplemental opioids, adequate analgesia is achievable. Stopping buprenorphine 72 hours preoperatively risks destabilisation and relapse. Intraoperative multi-modal analgesia (regional blocks, ketamine, NSAIDs) reduces opioid requirements. NSAIDs alone are insufficient for femur fracture pain.
Reference: Kaplan & Sadock's Synopsis of Psychiatry, 11th ed.
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Written and medically reviewed by the StethoPrep medical team.