Butrans and Anesthesia

[bedrock]

Can you anesthesia trained folks please direct me to guidelines for butrans and anesthesia?

My understanding is that it is safe to continue butrans (which fairly low dose compared to belbucca or oral bup), even in patients having GETA, because anesthesia can still give intraop/post op fentanyl and post-op PO oxy/Vicodin even while the patient continues butrans patch, because the fentanyl and post op oxy will overcome and supplement the butrans.

I’d appreciate it some of the anesthesia trained pain docs here could confirm my perspective and if so help me find some guidelines to share with the pure anesthesia docs in my ortho group, who are really conservative from an anesthesia perspective in many ways, not just this one.

If I’m missing something or wrong, Let me know too.

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[Norepi]

Sure, I can try to help. This information was shared with me during residency. You can tell your folks this is what they use at MGH, if that has any cache with them or you.
The flowsheet here is from Quaye and Zhang: Perioperative Management of Buprenorphine: Solving the Conundrum
doi: 10.1093/pm/pny217

This is for oral suboxone. Using package inserts and known bioavailability data for butrans, a 20 mcg/hr patch for instance delivers .48 mg/d of bup. a 4 mg suboxone leads to 1 mg bioavailable (25% absorbed). In any scenario, even at max dose butrans, you'd not hit the dose limit to consider dose adjustment, and you have plenty of receptors to go around. You can even council the conservative anesthesiologists that they can just use sufentanil if they are concerned, as it has superior receptor affinity over buprenorphine (the only species with superior affinity, IIRC).

The second figure here is from Greenwald MK, Comer SD, Fiellin DA. Buprenorphine maintenance and mu-opioid receptor availability in the treatment of opioid use disorder: implications for clinical use and policy. Drug Alcohol Depend. 2014 Nov 1;144:1-11. doi: 10.1016/j.drugalcdep.2014.07.035. Epub 2014 Aug 19. PMID: 25179217; PMCID: PMC4252738.

Clearly, at the doses concerned, you have plenty of open mu opioid receptors. There are other studies in publication to suggest that buprenorphine in concert with pure agonists may actually have a synergistic effect while maintaining buprenorphine's respiratory depressant aspects. I can whip these out if you're interested too.

Let me know if any other questions.

 

[deleted875186]

Can you anesthesia trained folks please direct me to guidelines for butrans and anesthesia?

My understanding is that it is safe to continue butrans (which fairly low dose compared to belbucca or oral bup), even in patients having GETA, because anesthesia can still give intraop/post op fentanyl and post-op PO oxy/Vicodin even while the patient continues butrans patch, because the fentanyl and post op oxy will overcome and supplement the butrans.

I’d appreciate it some of the anesthesia trained pain docs here could confirm my perspective and if so help me find some guidelines to share with the pure anesthesia docs in my ortho group, who are really conservative from an anesthesia perspective in many ways, not just this one.

If I’m missing something or wrong, Let me know too.

You are correct, I don’t think anyone has guidelines concerning Belbuca or Butrans though.

Most anesthesiooogists would still have you stop Butrans/Belbuca preop as there is no risk of relapse like in OUD, and stopping will likely help postop pain, or at worst have little effect. Also much less risk of withdrawal from Butrans or Belbuca compared to Suboxone.

 

[bedrock]

You are correct, I don’t think anyone has guidelines concerning Belbuca or Butrans though.

Most anesthesiooogists would still have you stop Butrans/Belbuca preop as there is no risk of relapse like in OUD, and stopping will likely help postop pain, or at worst have little effect. Also much less risk of withdrawal from Butrans or Belbuca compared to Suboxone.

I thought butrans 15 mcg must have an tiny effect compared to oral bup.

I’m a bit tired of how conservative our anesthesia group is. They consistently deny cases to our ASC, saying they must go to the HOPD. If you snore you’re practically always a HOPD case per them.

There is also bad blood between our group and the local hospital. So a couple surgeons are now doing a day per month at an ASC in a town 45 min away….and that anesthesia group accepts half of the cases that our anesthesia group says must be HOPD, yet somehow the other anesthesia group is fine with them.

 

[bedrock]

Sure, I can try to help. This information was shared with me during residency. You can tell your folks this is what they use at MGH, if that has any cache with them or you.
The flowsheet here is from Quaye and Zhang: Perioperative Management of Buprenorphine: Solving the Conundrum
doi: 10.1093/pm/pny217

This is for oral suboxone. Using package inserts and known bioavailability data for butrans, a 20 mcg/hr patch for instance delivers .48 mg/d of bup. a 4 mg suboxone leads to 1 mg bioavailable (25% absorbed). In any scenario, even at max dose butrans, you'd not hit the dose limit to consider dose adjustment, and you have plenty of receptors to go around. You can even council the conservative anesthesiologists that they can just use sufentanil if they are concerned, as it has superior receptor affinity over buprenorphine (the only species with superior affinity, IIRC).
View attachment 370879

The second figure here is from Greenwald MK, Comer SD, Fiellin DA. Buprenorphine maintenance and mu-opioid receptor availability in the treatment of opioid use disorder: implications for clinical use and policy. Drug Alcohol Depend. 2014 Nov 1;144:1-11. doi: 10.1016/j.drugalcdep.2014.07.035. Epub 2014 Aug 19. PMID: 25179217; PMCID: PMC4252738.

Clearly, at the doses concerned, you have plenty of open mu opioid receptors. There are other studies in publication to suggest that buprenorphine in concert with pure agonists may actually have a synergistic effect while maintaining buprenorphine's respiratory depressant aspects. I can whip these out if you're interested too.

Let me know if any other questions.


View attachment 370880

Thank you. Really appreciate the information!!
I did my PMR residency at Harvard. happy to to use the guidelines anesthesia uses at MGH.

 

[lobelsteve]

Sure, I can try to help. This information was shared with me during residency. You can tell your folks this is what they use at MGH, if that has any cache with them or you.
The flowsheet here is from Quaye and Zhang: Perioperative Management of Buprenorphine: Solving the Conundrum
doi: 10.1093/pm/pny217

This is for oral suboxone. Using package inserts and known bioavailability data for butrans, a 20 mcg/hr patch for instance delivers .48 mg/d of bup. a 4 mg suboxone leads to 1 mg bioavailable (25% absorbed). In any scenario, even at max dose butrans, you'd not hit the dose limit to consider dose adjustment, and you have plenty of receptors to go around. You can even council the conservative anesthesiologists that they can just use sufentanil if they are concerned, as it has superior receptor affinity over buprenorphine (the only species with superior affinity, IIRC).
View attachment 370879

The second figure here is from Greenwald MK, Comer SD, Fiellin DA. Buprenorphine maintenance and mu-opioid receptor availability in the treatment of opioid use disorder: implications for clinical use and policy. Drug Alcohol Depend. 2014 Nov 1;144:1-11. doi: 10.1016/j.drugalcdep.2014.07.035. Epub 2014 Aug 19. PMID: 25179217; PMCID: PMC4252738.

Clearly, at the doses concerned, you have plenty of open mu opioid receptors. There are other studies in publication to suggest that buprenorphine in concert with pure agonists may actually have a synergistic effect while maintaining buprenorphine's respiratory depressant aspects. I can whip these out if you're interested too.

Let me know if any other questions.


View attachment 370880

"like" wasn't enough. Thank you!

 

[Orin]

Great insight

ASRA had a recommendation paper a year or two ago: Buprenorphine management in the perioperative period: educational review and recommendations from a multisociety expert panel | Regional Anesthesia & Pain Medicine

The MGH or UCSF guidelines are pretty easy for folks to follow.

https://www.fresno.ucsf.edu/wp-content/uploads/2021/06/UCSF-Perioperative-Management.pdf

Belbuca/Butrans should be continued and treated like the patient's long acting agent

 

[drrosenrosen]

They follow the UCSF guidelines at Duke (or, at least they did when I was there) as well.