Intra-Operative Management of Acute Pain in Patients receiving Suboxone

Therapy
Lauren Toler, BSN
University of Pennsylvania
Anticipated date of graduation: May 2!"
#mai$ address: $auren%to$er&nursing%upenn%edu
'ey(ords: Suboxone, opioid dependent patients, heroin addicted patients, opioid-sparing
analgesia, ultiodal analgesia
!pioid addiction or dependence has garnered ne" attention recently as it affects alost # illion
individuals in the United States alone$ The rising nuber of opioid addicted individuals and
deaths related to unintentional drug overdose have propted treatent plans for patients that
include Suboxone therapy$ Suboxone, a cobination product "ith buprenorphine and naloxone,
"as introduced by the %&' in #((# for the treatent of narcotic addiction$
)
Traditional odes
of analgesia during surgery include the adinistration of opioids$ *o"ever, the intraoperative
anageent of patients ta+ing Suboxone should ai at providing non-opioid analgesia including
NS',&s, ,- acetainophen, alpha-# agonists, +etaine, and regional techni.ues$
)ase *eport:
' /0 year old ale, )1( c and )2( +g presented for a +nee arthroscopy edial enisectoy$
*is edical history "as significant for atrial fibrillation, astha, gastro-esophageal reflux
disease, depression, narcotic abuse, degenerative disc disease, and a #( pac+ year so+ing
history$ *is surgical history "as not significant for any prior anesthetic coplications$ *is
current edications consisted of alpra3ola ) g T,&, lansopra3ole )2 g once daily, albuterol
inhaler P4N, aitryptaline 52 g daily, aspirin /#2 g, diltia3e /( g T,&, and naproxen #((
g, and Suboxone )6 g daily$
' preoperative assessent of the patient revealed a 7allapati classification of ,,,, a
thyroental distance of 8 6c, inter-incisor distance of 8 9$2 c, and poor atlanto-occipital
extension secondary to degenerative dis+ disease$ ' preoperative discussion "ith the surgeon
"as held to discuss the use of local anesthetic at the surgical site, and the oission of intra-
articular orphine for pain relief$
,n the operating roo, standard 'S' onitors "ere applied$ 7ida3ola 9 g "as given as a
pre-edication anxiolytic$ The sniffing position "as achieved by placing blan+ets under the
upper bac+$ The patient "as pre-oxygenated "ith )((: !# at a flo" of )( L;in$ <eneral
anesthesia "as induced "ith lidocaine )(( g, propofol /(( g, and succinylcholine )2( g$
'fter loss of the lid reflex "as confired, direct laryngoscopy "as perfored "ith a 7'= /
blade and a <rade ,, vie" "as obtained$ >ndotracheal intubation "as achieved "ith an 0$(
endotracheal tube, and confired "ith bilateral breath sounds, and positive >T=!#$ Pressure
control ventilation "as initiated to aintain tidal volues of 6((-5(( L and an >T=!# of /(-/2
*g$ <eneral anesthesia "as aintained "ith desflurane 6: inspired concentration in a
ixture of oxygen # L;in$ /2 L of ($#2: bupivicaine "as in?ected into the +nee ?oint by the
surgeon$ @etorolac /( g "as given both intravenously and intrauscularly$ )2(( L of
Lactated 4ingers "ere adinistered$
't the conclusion of the case, desflurane "as "eaned off$ )((: !# "as adinistered at flo"s of
)(L;in$ Spontaneously ventilation "as initiated by the patient$ !nce a regular respiratory rate
and rhyth "ere achieved, along "ith purposeful oveents, the patient "as extubated and
transferred to the post anesthesia care unit AP'=UB "ith suppleental oxygen at 6 L;in$ The
patient denied pain upon arrival to the P'=U$
+iscussion:
Suboxone is a cobination drug that contains buprenorphine and naloxone in a ratio of 9:)$
), #
,t
is becoing increasing popular in the treatent of addiction due to its safe edication profile
and lo" potential for abuse$ Cith thousands of individuals aintained on Suboxone therapy
presenting to the surgical arena each year, the intraoperative anageent of these patients
presents anesthesia providers "ith a uni.ue set of considerations$ Suboxone has a strong affinity
to bind to the u receptor for durations of #9-6( hours preventing other u agonists fro being
effective$
#
'de.uate pain anageent in these individuals proves to be a challenge, and other
odes of analgesia ust be considered$
4ecoendations for pain anageent include continuing or increasing the prescribed dose the
day of surgery to prevent "ithdra"al syptos and provide soe pain relief$ 't higher doses
ho"ever, buprenorphineDs agonist effects plateau providing a ceiling effect$
#
,f high clinical
doses are reached, this option ay be rendered useless as effective analgesia ay not be
produced$ Suggestions also include utili3ing short acting opioids, such as fentanyl in addition to
buprenorphine aintenance$ ,f this is considered, large doses of opioid "ill be needed to
overcoe the high affinity and partial antagonist effects of buprenorphine$ The ris+ associated
"ith this option is post-operative sedation, respiratory depression, and ris+ of restarting opioid
addiction$
#, /
,deally, a ultiodal, opioid sparing approach to pain anageent should be developed$ %or
this patient, the scheduled daily dose of Suboxone "as continued the day of surgery, and
ultiodal analgesia "as accoplished using local anesthetic at the site of surgery, and use of
+etorolac, a non-steroidal anti-inflaatory drug ANS',&B$
Bupivicaine "as chosen as the local for infiltration for its rapid onset, relative potency and long
duration of action$ The eliination half tie is approxiately /$2 hours, covering the duration of
the surgical procedure and providing post-operative pain relief$
@etorolac inhibits cyclooxygenase, decreasing the foration of prostaglandins and throboxane,
t"o cheical ediators associated "ith producing pain$ ,t is a potent analgesic and has oderate
anti-inflaatory activity "hen given intrauscularly or intravenously$ ,t is useful for
postoperative analgesia as the sole drug, or to suppleent opioids$ @etorolac /(g intrauscular
is e.uivalent to orphine )(g$
9
' eta-analysis of thirteen randoi3ed clinical trials
concluded that +etorolac "as an effective ad?unct in postoperative pain anageent$
2
@etorolac
"as chosen as it is readily available in the operating roo, its efficacy in producing ade.uate
pain control "ithout producing respiratory depression and sedation and the patientDs edical
history "as not reflective of any contraindications to using +etorolac, including renal disease,
severe astha, aspirin sensitivity, nasal polyposis, and bleeding disorders$
'nother ode of analgesia that "as considered in the perioperative pain anageent of this
patient is +etaine, an ,-ethyl-d-aspartate AN7&'B receptor antagonist$ N7&' is one of the
best studied regulators of pain signaling$ N7&' receptors are expressed in various areas in the
peripheral and central nervous systes controlling pain sensiti3ation and neural plasticity in
any acute and chronic pain states.
6
Chronic opioid consumption also produces changes in the
nervous system similar to that seen with central sensitization.
5
For this reason, ketamine proves
to be an effective adjuvant to analgesia in the opioid dependent population. Perioperative
subanesthetic doses of +etaine reduces rescue analgesic re.uireents by /(-2(:$
0
,n addition
to its opioid sparing effect, +etaine could reduce the developent of chronic postoperative pain
through N7&' receptor bloc+ade and reduction of central sensiti3ation$
0
@etaine has
properties of sypathetic nervous syste stiulation "hen adinistered$ The decision to
exclude +etaine fro this patientDs plan of care "as based on his history of atrial fibrillation, as
not to exacerbate syptos$
Patients receiving Suboxone therapy, or other agonist-antagonists as part of addiction
rehabilitation re.uire a ultiodal approach to pain anageent$ Chile specific guidelines
have not yet been established on ho" to appropriately anage acute pain in this uni.ue, but
gro"ing population, recoendations have been ade$ Utili3ing regional techni.ues "hen
appropriate proves to be an effective alternative to a traditional narcotic based anesthetic$
*o"ever, in situations "here regional techni.ues are contraindicated, other pharacotherapies
including NS',&s, ,- acetainophen, +etaine, and alpha-# agonists have been sho"n to be
effective, and should be considered$
*eferences:
)$ Ling C$ Buprenorphine for opioid dependence$ >xpert 4ev Neurother$ #((1E1A2B:6(1-
6)6$ doi:)($)206;ern$(1$#6
#$ Bryson >!, Lipson S, <evirt3 =$ 'nesthesia for Patients on Buprenorphine$
Anesthesio$ )$in% #()(E #0A9B:6))-6)5$ doi:)($)()6;?$anclin$#()($(0$((2$
/$ =hern SFS, ,sseran 4, =hen L, 'shburn 7, Liu 4$ Perioperative Pain 7anageent for
Patients on =hronic Buprenorphine: ' =ase 4eport$ - Anesth )$in *es% #()#E/A)(B$
doi:)($9)5#;#)22-6)90$)(((#2(
9$ @reer, 7$ Nonopioid 'nalgesics and Their 4ole in 'nesthesia Practice$ ,n: !uellette
4<, Goyce G', ed$ Pharmaco$ogy for ,urse Anesthesio$ogy% Sudbury, 7': Gones
and Bartlett LearningE #()): 0/-09$
2$ &e !liveira <S, 'gar"al &, Ben3on *T$ Perioperative single dose +etorolac to prevent
post-operative pain: a eta-analysis of randoi3ed clinical trials$ Anesth Ana$g%
#()#E))9A#B:9#9-//$ doi: )($)#)/;'N>$(b()/e/)0#//9d60$
6$ 'ngst 7S, =lar+, G&$ @etaine for 7anaging Perioperative Pain in !pioid-dependent
Patients "ith =hronic Pain$ Anesthesio$ogy% #()(E))/A/B:2)9-2)2$ doi:
)($)(15;'LN$(b()/e/)0)e1(1#d
5$ 4aas"ay S, Cilson G', =olvin L$ Non-opioid-based ad?uvant analgesia in
perioperative care$ =ontinuing >ducation in 'nesthesia, =ritical =are H Pain$
#()/E)/A2B:)2#-)25$ doi:)($)(1/;b?aceaccp;+t()#$
0$ Bell 4%, &ahl GB, 7oore, '4, @also >'$ A#()(B$ Perioperative +etaine for acute
postoperative pain$ )ochrine +atabase of Systematic *evie(s% #((6E):)-9/$
Mentor: @elly L$ Ciltse Nicely, Ph&, =4N'
(i$tse&nursing%upenn%edu