Perioperative buprenorphine and methadone

Do not stop buprenorphine or methadone for surgery: continue the maintenance dose to prevent withdrawal and relapse, then layer multimodal analgesia and, if needed, full-agonist opioids at higher-than-usual doses.

1. Buprenorphine continues through surgery. A five-society working group reached 100% consensus that buprenorphine should not be routinely discontinued perioperatively, to lower the risk of opioid use disorder recurrence ¹.
2. Surgery can be a starting point. The same group endorsed initiating buprenorphine perioperatively in untreated patients with opioid use disorder and acute pain, to reduce recurrence and overdose death ¹.
3. Buprenorphine binds tightly. It is a mu partial agonist with strong receptor affinity and slow dissociation, and a kappa antagonist; patients may need higher full-agonist doses to overcome the bound buprenorphine ².
4. Maintenance methadone does not cover acute pain. The label states maintenance patients cannot be expected to get analgesia from their existing dose and need analgesics, often at higher or more frequent doses because of tolerance ³.
5. Keep methadone going. Continue the usual dose on the morning of surgery; if oral intake is impossible, parenteral methadone at half to two-thirds of the maintenance dose, divided into 2–4 doses daily, can be used ².
6. Build a multimodal plan. Regional anesthesia, acetaminophen, NSAIDs, ketamine and clonidine can reduce opioid needs, with oral or IV opioids, including PCA, titrated to effect ¹².

High-dose methadone can prolong the QT interval and cause torsade de pointes, especially with other QT-prolonging drugs; check for co-administered QT-prolonging drugs when planning perioperative medications ².

• Interrupting buprenorphine raises the risk of opioid use disorder recurrence and overdose ¹.
• Buprenorphine is poorly absorbed orally and is given sublingually, transdermally or parenterally; its half-life varies by route ².
• On low-dose buprenorphine (2–8 mg/day), dosing every 6–8 hours can use it as an analgesic ².
• Methadone conversion calculations may not work in both directions because of its long half-life ².
• Typical methadone maintenance doses for opioid use disorder are 60–120 mg/day ².
• Abrupt discontinuation of methadone maintenance is associated with withdrawal and relapse ³.
• Buprenorphine or methadone should not be withheld from patients taking benzodiazepines, though caution is needed ⁴.
• Ketamine may be considered for opioid-dependent or opioid-tolerant patients undergoing surgery ⁵.

• Stopping buprenorphine days before elective surgery by routine ¹.
• Counting the maintenance methadone dose as the patient's analgesia; a daily dose for opioid use disorder is inadequate for acute pain ²³.
• Assuming regional anesthesia alone reliably cuts opioid use; one case series found inconsistent effect ².
• Withholding full-agonist opioids from a patient on buprenorphine with uncontrolled pain ².