Perioperative Analgesic Approach to Patients on Baseline Opioid Antagonist or Mixed Agonist/antagonist Therapy

Managing patients and optimizing peri-operative outcomes in patients prescribed either opioid antagonistsOpioid antagonist or mixed agonists/antagonistsMixed agonist/antagonist therapy requires strategic planning and specific knowledge of the pharmacokinetics/pharmacodynamics of these agents. Opioid antagonistsOpioid antagonist, including naloxoneNaloxone and naltrexoneNaltrexone, block opioidOpioids receptors and displace opioidOpioids agonists due to their higher affinity for the receptor. Mixed agonist/antagonist therapeuticsMixed agonist/antagonist therapy include buprenorphineBuprenorphine, butorphanol, nalbuphineNalbuphine, and pentazocine, with buprenorphineBuprenorphine being the most commonly used, currently. Indications for this class of drugs include reversal of respiratory depressionDepression caused by opioidsOpioids, reversal of opioidOpioids overdoseOverdose, reduction in the riskRisks of opioidOpioids abuse, and prevention of relapse in those addicted to opioidsOpioids or alcohol. With addictionAddiction and opioid use disordersOpioid use disorder ascending to become a public health crisis in the United States, the number of patients presenting for surgery prescribed or otherwise self-administering either antagonists or mixed agonist/antagonists has increased. Perioperative analgesiaPerioperative analgesia can be substantially challenging in these patients and therefore instituting appropriate screening and planning management prior to day of surgery is imperative. For patients taking naltrexoneNaltrexone, it is important to contact the provider managing the patient’s prescription to understand indications and formulate a plan for analgesicAnalgesics strategies. NaltrexoneNaltrexone should be stopped before a major surgery in order to provide effective analgesiaAnalgesia; this requires either 72 hours prior to procedure for the oral formulation, and 4 weeks for the injectable formulation. Buprenoprhine-naloxoneNaloxone can be continued throughout the perioperative periodPerioperative period to reduce the riskRisks of relapse. For isolated buprenorphineBuprenorphine preparations, the intrinsic analgesicAnalgesics properties of this agent and altered dosing regimens may be harnessed to provide enhanced analgesiaAnalgesia. For any of these partial agonist/antagonist agents, multimodal pain regimens are incredibly useful. With naltrexoneNaltrexone, it is important to closely monitor patients for signs of overdoseOverdose, and non-opioid strategies may need to be employed in emergent situations when pre-operative planning is not possible. Follow-up with the patient’s regular prescriber for both naltrexoneNaltrexone and buprenorphineBuprenorphine-naloxoneNaloxone is critical to ensure appropriate continuation of their prescriptions.