Continuation versus Interruption of Buprenorphine/Naloxone in Adult Veterans Undergoing Surgery: Examination of Postoperative Pain and Opioid Utilization in a National Retrospective Cohort Study

Background Prescription rates for buprenorphine in opioid use disorder are increasing, and recent guidelines recommend its continuation during and after surgery; however, evidence from clinical outcome studies is limited. We tested the hypotheses that 1) perioperative continuation of buprenorphine does not result in higher pain scores and 2) that this approach does not result in higher supplemental postoperative opioid requirements. Methods The Veterans Affairs Corporate Data Warehouse was queried for patients who underwent surgery while being prescribed buprenorphine/naloxone for opioid use disorder between 2010 and 2020. Analysis of the prescription record was used to infer buprenorphine management, and a 3:1 matched control set of patients without buprenorphine prescriptions was generated. We examined patients who continued buprenorphine, patients who had buprenorphine interrupted, and control patients. The primary outcome was time-weighted average postoperative pain scores from inpatient and outpatient sources within 72 hours of surgery. The secondary outcome was postoperative average daily morphine equivalent opioid requirements within two weeks of surgery. Results A total of 1,881 surgical procedures in 1,673 patients taking buprenorphine for opioid use disorder were included; these procedures were matched to 5,748 control patients (5,775 procedures) without a buprenorphine prescription. Among the 1,881 procedures, 1,186 (63%) continued buprenorphine through the perioperative period while 695 (37%) interrupted buprenorphine. Pain scores were clinically similar for all three groups (4.1 ± 1.9 control [n = 3284], 4.9 ± 2.0 continued buprenorphine [n = 662], and 5.5 ± 1.7 interrupted buprenorphine [n = 419]; P < 0.001).Patients who continued buprenorphine did not require significantly more supplemental opioids as compared to controls (39.7 mg morphine equivalents/day ± 1.9 versus 36.5 ± 0.7, P = 0.23), and patients who interrupted buprenorphine received more supplemental opioids than those who continued it (74.2 ± 4.5 mg morphine equivalents/day versus 39.7 ± 1.9,respectively; P < 0.001). Conclusions Continuation of buprenorphine is not associated with higher average pain scores or postoperative opioid requirements, supporting recently published guidelines.