Stop Buprenorphine. As noted above, continuing buprenorphine after surgery can antagonize the effects of other opioids prescribed for postoperative pain. Discontinuing buprenorphine may help in making those opioids more effective. As postoperative pain diminishes over time and opioid requirements decrease, buprenorphine therapy can be restarted.
Continue Buprenorphine. Some experts contend that buprenorphine can be continued, although it may be necessary to treat with higher doses of opioids to compete for mu receptors. There are some controlled studies showing effectiveness of average doses of opioids for breakthrough pain in patients on the buprenorphine patch.1-2 Remember that this provides a much lower dose of buprenorphine than what is more commonly used for opioid dependence in sublingual formulations. However, other studies support the concept that effective pain management can be achieved with higher dose opioids in patients on higher dose buprenorphine.3-4
Rotate to Methadone. If your institution has the necessary specialists, you can also consider rotating the patient to methadone for maintenance during the postoperative period. Since methadone is a full agonist, it removes the problems associated with mu receptor blockade while keeping the patient on treatment for their addiction. However, practitioners need to take into consideration the potential difficulties with transitioning a patient between these two agents and the restrictions on prescribing methadone at discharge.
Determine Buprenorphine Use based on Risk. Lately, pain specialists have been taking a more stratified approach (Figure 1). For more high risk or major surgeries, they recommend stopping buprenorphine to maximize opioid efficacy. For minor surgeries, they recommend continuing buprenorphine, as pain can often be controlled with non-opioid therapies. The result is a protocol based on risk stratification.
Surgeries that are more painful will require higher opioid consumption, even in opioid naïve patients. In these situations, where the risk for complications related to uncontrolled pain outweigh the benefits of maintaining buprenorphine therapy – this approach recommends discontinuing buprenorphine. In other more minor surgeries, where pain is often controlled with minimal to no opioids, it may not be necessary to stop buprenorphine to manage pain effectively.
http://cpnp.org/resource/mhc/2011/09/buprenorphine-and-acute-pain-management
), or at least take pity and knock me out cold.