Optimizing Safe Opioid Prescribing: A Paradigm Shift in Buprenorphine Management for Orthopedic Surgery

The worsening opioid epidemic in the United States, exacerbated by the COVID-19 pandemic, necessitates innovative approaches to pain management. Buprenorphine, a long-acting opioid, has gained popularity due to its safety profile and accessibility. Orthopaedic surgeons, encountering an increasing number of patients on buprenorphine, face challenges in peri-operative management. This article will update orthopaedic surgeons on new developments in the understanding of buprenorphine as a pain reliever and share evidence-based practice guidelines for buprenorphine management. For patients on buprenorphine for opioid use disorder or chronic pain, the updated recommendation is to continue their home dose of buprenorphine through the peri-operative period. The patient's buprenorphine prescriber should be contacted and notified of any impending surgery. The continuation of buprenorphine should be accompanied by a multimodal approach to analgesia, including a pre-operative discussion about expectations of pain and pain control, regional anesthesia, standing acetaminophen, Non-steroidal anti-inflammatory drugs (NSAIDs) when possible, gabapentinoids at night for patients under 65 years, cryotherapy, elevation, and early mobilization. Patients can also be prescribed short-acting, immediate release opioids for breakthrough pain. Transdermal buprenorphine (TDB) is emerging as an excellent option for the management of acute perioperative pain in both elective and non-elective orthopaedic patients. A single patch can provide a steady dose of pain medication for up to one week during the post operative period. A patch delivery method can help combat patient nonadherence and ultimately provide better overall pain control. In the future, TDB patches could be applied in virtually all fracture surgery, spinal surgery, total joint arthroplasty, ligament reconstructions with bony drilling, et cetera. As the stigma surrounding Buprenorphine decreases, further opportunities for perioperative use may develop.