Perioperative management of a patient undergoing Clagett window closure stabilized on Suboxone® for chronic pain: a case report.

PURPOSE: Buprenorphine is a semisynthetic opioid with both agonist and antagonist activity at the opioid receptor. Currently, buprenorphine is commonly available in sublingual preparations combined with naloxone (e.g., Suboxone®, Subutex®). There has been increased use of buprenorphine derivatives in the areas of substance addiction and chronic pain. Nevertheless, there is limited and conflicting information in the literature pertaining to the optimal management of buprenorphine-stabilized patients presenting for surgery. We present our experience with a chronic pain patient on buprenorphine presenting for thoracic surgery. CLINICAL FEATURES: A 47-yr-old female with a history of a Clagett window procedure for pulmonary aspergillosis and subsequent chronic pain presented to our institute for a window closure procedure. Preoperatively, her pain regimen included Suboxone 16 mg bid, which was continued perioperatively. Postoperatively, her course was complicated by suboptimal pain at the surgical site requiring in excess of 70 mg/24 hr of intravenous hydromorphone. Liberal addition of long-acting oral opioids was ineffective in improving pain management. Eventually, concern was raised regarding opioid receptor blockade by her long-acting Suboxone, and the decision was made to taper her Suboxone. Following this, her pain control improved dramatically and her opioid requirements were markedly reduced. By discharge, her Suboxone was discontinued and she was managed on oral hydromorphone.
CONCLUSION: In a chronic pain patient continued on Suboxone perioperatively, significant improvement in control of postoperative pain was observed following tapered doses, and eventually her use of Suboxone was discontinued. This case highlights the potential for opioid receptor blockade by Suboxone, which can interfere with acute pain management.