49th Annual Regional Anesthesiology and Acute Pain Medicine Meeting

Acute Pain Service Improves Perioperative Pain Management and Helps Prevent Relapses in Patients with Opioid Use Disorder

Sierra Mastrantonio, MD, Jacob Whittle, MD, Jacob Brandenburg, MD, Jacob Pollard, MD,

Emily Drennan, MD, Eric Piacenza, MD, Evelyn Loose, MD

University of Utah Health, Department of Anesthesiology

Background

•The perioperative period is a vulnerable time for patients with opioid use disorder (OUD)

•Risk of relapse vs achieving adequate pain control

•FDA approved medications for opioid use disorder (MOUD) (1-3)

•Buprenorphine, Methadone, Naltrexone

•↓ relapse rate, ↓ mortality

•↑ retention in cognitive & behavioral therapy, ↑ quality of life

•Buprenorphine (4,5)

•High affinity, slow kinetic dissociation opioid analgesic

Case Description

•49 y/o F longstanding history OUD and methamphetamine use disorder

•Multiple hospitalizations for endocarditis, epidural abscesses, septic joints

•On buprenorphine-naloxone as (prior) inpatient → lost to follow up after discharge

•Transitional Pain Service (TPS) was consulted on patient’s 2023 admission for a repeat total knee arthroplasty (TKA)

Pre-operatively:

•Re-established care with an addiction specialist

•Continued buprenorphine-naloxone 4mg BID

•Patient expressed desired avoidance of full opioid agonists due to concern for relapse

Intraoperative analgesia:

•Periarticular injection (Ortho) : ropivacaine 0.5%, ketorolac, epinephrine, clonidine

•IV acetaminophen, ketorolac, dexmedetomidine, ketamine

Post-operative analgesia:

•Continuous femoral nerve blockade w/ indwelling perineural catheter x 4 days post-op: bupivacaine 0.25% + epi

•Non-opioid multimodal analgesia: acetaminophen, aspirin, gabapentin, ketamine, meloxicam

•↑ buprenorphine-naloxone: 4mg BID + 4mg daily as needed

✩ 7-month follow up: remained on buprenorphine-naloxone w/no use of full opioid agonists→ Maintained recovery!

Discussion

•Evidence-based approaches to buprenorphine management in the perioperative setting can improve outcomes in patients with OUD

•Expertise of acute pain physicians in complex pain management and regional techniques can achieve adequate perioperative analgesia without the use of full opioids agonists

“My pain control on Suboxone only and all the other things you did was so much better than any of the other times being treated with Methadone and Dilaudid… I did not want to be in pain and go back to using [drugs] again. Thank you for giving me the opportunity to live.”

References: 1. Kakko J, Svanborg KD, Kreek MJ, Heilig M. 1-year retention and social function after buprenorphine-assisted relapse prevention treatment for heroin dependence in Sweden: a randomised, placebo-controlled trial. Lancet. 2003 Feb 22;361(9358):662-8. doi: 10.1016/S0140-6736(03)12600-1. PMID: 12606177., 2. Mattick RP, Breen C, Kimber J, Davoli M. Buprenorphine maintenance versus placebo or methadone maintenance for opioid dependence. Cochrane Database Syst Rev. 2014 Feb 6;2014(2):CD002207. doi: 10.1002/14651858.CD002207.pub4. PMID: 24500948; PMCID: PMC10617756., 3. Watts BV, Gottlieb DJ, Riblet NB, Gui J, Shiner B. Association of Medication Treatment for Opioid Use Disorder With Suicide Mortality. Am J Psychiatry. 2022 Apr;179(4):298-304. doi: 10.1176/appi.ajp.2021.21070700. PMID: 35360916. 4. American Society of Addiction Medicine (ASAM). The ASAM national practice guideline for the treatment of opioid use disorder: 2020 focused update. J Addict Med. 2020;14(2S)(suppl 1):1‐91. doi:10.1097/ADM.0000000000000633 [PubMed 32511106], 5. De Aquino JP, Parida S, Sofuoglu M. The pharmacology of buprenorphine microinduction for opioid use disorder. Clin Drug Investig. 2021;41(5):425-436. doi:10.1007/s40261-021-01032-7 [PubMed 33818748]

49th Annual Regional Anesthesiology and Acute Pain Medicine Meeting

ACUTE PAIN SERVICE IMPROVES PERIOPERATIVE PAIN MANAGEMENT AND HELPS PREVENT RELAPSES IN PATIENTS WITH OPIOID USE DISORDER

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