Evaluating the use of sublingual sufentanil in patients with buprenorphine treatment who are undergoing ambulatory surgery: A Prospective Case Series

Authors:  Kateryna Slinchenkova1 BA, Elilary Montilla Medrano2 MD, Adam S. Yedlin2 MD, Preeti Anand2 MD, Karina Gritsenko2 MD, Sofia Steinberg2 DO,  Kathryn Breidenbach2 MD, Sarang Koushik3 MD, Naum Shaparin2 MD

Affiliations: 1. New York Medical College School of Medicine, Valhalla, NY, USA 2. Department of Anesthesiology, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY, USA 3. Department of Anesthesiology, Valleywise Health Medical Center, Creighton University School of Medicine, Phoenix, AZ, USA

Background

One of the long-term management options to avoid opioid use relapse is to include an opioid agonist (methadone or buprenorphine) in the management regime. (1,2) The number of Medicaid-covered prescriptions for buprenorphine containing products for treatment has increased 5-fold from 2011 to 2018. (3) Since the guideline change in 2021, providers no longer need additional training or licensure to prescribe buprenorphine, so prescription numbers and access to this medication have an expectation to increase further. Recommendations for perioperative treatment of patients on suboxone have varied in recent years, with many discussions on a need for discontinuation or tapering of dose due to the potential for pain control difficulties. (4) Recent guidelines have pivoted to suggest that buprenorphine should be continued, and postoperative pain management can be achieved with the focused utilization of regional anesthesia and IV non-opioid anesthesia, with opioids acting as a supplement. Nevertheless, conversion to methadone or morphine is noted as an option to avoid difficulties.(5) A multimodal approach to analgesia and communication with prescribing provider is recommended. (6) There is a known concern that increased IV medication and increased opioid need to achieve pain control can lead to adverse effects such as nausea, respiratory depression, and more. Furthermore, the need for this intervention may increase patient length of stay and require increased monitoring. One potential medication that may assist with such issues is sufentanil.

Overall, a literature review of the sublingual sufentanil tablet (SST) found it to be an excellent treatment for chronic pain patients, reducing the need for IV medication. (7) In non-opioid tolerant patients, it has shown great success. Two randomized trials of different SST dosages showed that it significantly reduced pain intensity. Both studies indicated an increased rate of nausea for those not in the placebo group. (8, 9) Lower PACU opioid administration was noted (10) and those receiving sublingual sufentanil experienced less oxygen desaturation below 95% (p=0.028). (11) No research is currently available on the efficacy of sublingual sufentanil in opioid-tolerant patients.

Methods and Materials

Patients were screened using a weekly patient report of upcoming surgeries. Patients meeting the following criteria were approached for study participation:

Patients meeting criteria were called prior to surgery to offer participation in the study. Informed consent discussion was done over phone and written consent was obtained the morning of surgery.

The study was IRB-approved by Einstein IRB and sponsored by AcelRx Pharmaceuticals as an investigator-initiated trial. All three patients enrolled received 975mg acetaminophen preoperatively, and standardized general anesthesia, as per site protocol. The sublingual sufentanil tablet was administered by the attending anesthesiologist immediately following induction of general anesthesia.

Patients were evaluated for adverse effects upon entering recovery, an hour after recovery start, and 24 hours after discharge.

Cases

Discussion

While the results of the 3 cases cannot be taken as conclusive evidence of sublingual sufentanil efficacy in opioid-tolerant patients, it demonstrates an important option for pain management for patients on varying doses of suboxone. All three patients treated had no adverse effects and tolerated recovery room pain well. It is worth noting that in the patient who experienced the most pain, sufentanil administration was effective in lowering the pain from 10/10 to a 2/10. When completing a follow up call, after sufentanil has been cleared, pain control was no longer adequate. The contrasting minimal need for analgesia is novel due to numerous previous case reports reporting a high level of difficulty and complication when treating patients on buprenorphine.

While it is difficult to compare the expected pain from the varied procedures discussed in reports, the end results are worth noting. Pain management using sublingual sufentanil is fast, effective, and minimally invasive allowing for repeat dosing if needed. Its pharmacological profile allows for doses to be kept low, which limits the risk of adverse events such as respiratory depression. The treatment of acute pain plays a major role in preventing chronic pain development (17) While the patients on buprenorphine are already being treated for pain, preventing further chronic pain development in addition to their baseline helps keep medication doses constant and prevent quality of life changes.

Overall, further research is needed to attest for the efficacy of sublingual sufentanil in opioid-tolerant patients. However, the case report presented speaks for the benefit of individual consideration and implementation due to excellent pain management and lack of adverse events seen.

Conclusions