Thread by @RedMDND

Inspired by this article, here’s my first tweetorial on the Perioperative Care of Patients on Bupeprenorphine. This is an important topic for all surgeons, particularly trauma surgeons, as our patients may have a high rate of Opioid Use Disorder. journalofhospitalmedicine.com/jhospmed/artic…

1. Bupenorphine is a partial agonist at the mu-opioid receptor. Despite being a partial agonist, it has an extremely high affinity for the receptor and is 25-50x stronger than morphine.

2. Bupe has been used for treatment of pain since the early 80s but was approved by the FDA for the treatment of Opioid Use Disorder (OUD) in 2002.
3. The two most common formulations are Subutex (bupe only, safe in pregnancy) and Suboxone (4:1 mix of bupe and naloxone)

4. Based on the DATA 2000 act, outpatient rx of bupe is limited to providers with an X waiver.
5. Getting an X waiver is relatively painless. Either fours online and four in person or Eight hour online course (free). Info 👇🏻
pcssnow.org/medication-ass…

6. For your patients coming in on bupe: Continue it!
Stopping bupe is destabilizing for patients with OUD and relapse rates can be up to 90%.
7. Confirm patient’s dose by either checking the prescription drug database or calling patient’s Opioid Treatment Program (OTP).

8. If pt gets their bupe from an OTP (aka methadone clinic), the rx will not show up in state drug prescription monitoring program. Call OTP instead.
9. Use multimodal pain control. If opioids needed, use those with high mu receptor activity (fentanyl, morphine, hydromorphone).

10. Patients will likely need higher doses of opioids as a majority (but not all) of their mu opioid receptors will be occupied.
11. Consider splitting daily bupe dose into tid dosing (to take advantage of analgesic properties of bupe).

12. Know your rights: any physician (including all those WITHOUT X waiver) can continue bupe in the hospital and can change the dose (including increasing or splitting) as long as primary admitting diagnosis is NOT opioid use disorder. More info 👇🏻
files.constantcontact.com/023aa8ab001/85…

More awesome info from Project Shout (projectshout.org) here 👇🏻
static1.squarespace.com/static/5acbce8…

Please DM me for more info!
My hope is that we can support our patients with OUD throughout the perioperative period by supporting their recovery, reducing their risk of relapse and providing excellent pain management. @RASACS @NCSurgeons @traumadoctors @EAST_TRAUMA @ACSTrauma

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